HomeMy WebLinkAboutTAKII SARA 410 tatement of Organization
Recipient Committee
Statement Type ~lnltlal
Not yet qualified [] or
Type or print In ink
[] Amendment
List I.D. number:
#
Deta ~.~alified as ~mmi~e De~ quafi~d as C~mi~e
1. Committee Information
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AR~C,,,~E~:%~
MAILING ADDRESS (IF DIFFERENT)
Date Stamp
[] Termination - See Part 5
List I.D. number:
#
I L__
Date of Termination
00 AUG 18 PH 2:26
8AF, ERS~: iL[.;~, Cf i' Y Ct.E'~
STATEMENT OF ORGANIZATION
CALIFORNIA
For Official Use Only
2. Treasurer and Other Principal Officer
NAME OF TREASURER
MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
MAILING ADDRESS
OPTIONAL: FAX/E-MAILADDRESS
COUNTY OF DOMICILE
COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
Attach additional information on appropriately labeled continuation sheets.
3o Verification
CITY STATE ZIP CODE AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and complete. I cedify under penalty of
perjury under the laws of the State of California that the foregoing is true and correct,
Executed on (;~ '\~,' ~:~
DATE
Executedo. Do
DATE
Exec~ on
Exec~ on
DATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (8;99)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
4, Type of Committee Complete the applicable sections.
STATEMENT OF ORGANIZATION
C, L,FORN,,, 4 10
FORM
NUMBER
· List the name of each controlling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled, also list the elective office sought or held, and
district number, if any, and the year of the election.
· List the political pady with which each officeholder or candidate is affiliated or check "non-partisan."
· If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
on-Padisan
· List the financial institution and the disposilion of surplus funds (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION
BANK ACCOUNT NUMBER
DIBPOBff~ON OP SURPLUS FUNDS
W'Jlla#1~,ldllrli,ldHI~,J'e'Z, Jlaiflltl~:#.i Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TR1,E (iNCLUDE BALLOT NO. OR LETTER)
CANDI DATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE D STR CT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT ~ OPPOSE
SUPPORT OPPOSE
FPPC Form 410 (8/99)
For Technical Assistance: 916/322-5660
Statement of Organization
Recipient Committee CALIFORNIA410
FORM
INSTRUCTIONS ON REVERSE
COMMITTEE NAME .D. NUMBER
4. Type of Committee (Co.tinoed)
Notformedtosupportoropposespecificcsndidatesormeasumsinasfngleelection. Checkonlyonebox:
[] CITY Committee [] COUNTY Committee [] STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
STATEMENT OF ORGANIT, ATION
MAILINGADDRESS NO. AND STREET
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
CI~Y STATE
ZIP CODE
!:li,~x,l:~.l.-z..z,lex,jf#l,lll~-.a [] (For purposes of special election contribution limits)
· This committee has ceased to receive contributions and make expenditures;
· This committee does not anticipate receiving contributions or making expenditures in the future;
· This committee has eliminated or has no intention or ability to discharge all debts, loans received, and other obligations;
· This committee has no surplus funds; and
· This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions.
-- There are restrictions on the disposition of surplus campaign funds held by elected officem who are leaving office and by defeated candidates. Refer to
the information Manual on Campaiun Disclosure Provisions of the Political Reform Act. for Elected Officers, Candidates and their Controlled Committees
(Manual A).
-- Additional filing obligations will be incurred if, after terminating, the committee receives or spends any funds, or receives the forgiveness of a loan,
repayments of loans made to others, or any other receipts.
FPPC Form 410 (8/99)
For Technical Assistance: 91613~2-5660