HomeMy WebLinkAboutVEREEN 410 INITIAL 2/21/13Statement of Organization
Recipient Committee
Statement Type (initial
Not yet qualified ❑ or
NAME OF
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❑ Amendment
List I.U. number:
Date qualified as committee Date qualified as committee
(If applicable)
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❑ Termination — See Part S FEB 2 6 -o i
List I.D. number: 13 FEB 2 OftMj
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Date of Termination
STREET ADDRESS IND P.O. BOX)
CITY STATE ZIPCODE AREA CODEIPHONE
MAILING ADDRESS (IF DIFFERENT)
(
)URISDICTION WHERE COMMITTEE IS
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OF TREASURER
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For Official Use Only
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STREET ADDRESS (NO P.D. BC
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NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOx)
CITY
STATE CIP COUt .— 'wnf —n
Executed on
DATE
Executed on
DATE
Executed on
DATE
By
OF TREASURER OR ASSISTANT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER. CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC f=orm 410 (Dec /2012)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
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Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
2 C>
• All committees must list the financial institution where the campaign bank account is located.
Page 2
I.D. 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 party with which each officeholder or candidate is affiliated or check "nonpartisan."
• 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
Primarily Formed Committee I Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURES) JURISDICTION
(INCLUDE DISTRICT NO.. CITY OR COUNTY. AS APPLICABLE)
CHECK ONE
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Nonpartisan
SUPPORT
❑ Nonpartisan
Primarily Formed Committee I Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURES) JURISDICTION
(INCLUDE DISTRICT NO.. CITY OR COUNTY. AS APPLICABLE)
CHECK ONE
FPPC Form 410 (Dec /2012)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www,fppc.ca.gov
SUPPORT
❑
OPPOSE
❑
SUPPORT
OPPOSE
FPPC Form 410 (Dec /2012)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www,fppc.ca.gov