HomeMy WebLinkAboutCOUCH 410 TERM 06/30/11Statement of Organization Typeor'r L" ► STATEMENT OF ORGANIZATION
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Recipient Committee ELCGT1W1 Dot"sta'"p
Statement Type
i5
❑ Initial
Not yet qualified ❑ or
1._J
Date qualified as committee
❑ Amendment Termination -See Part 5
List I.D. nu Ifl AUG ! CJ PH 41i (P. number.
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- 2011
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Date qualified as committee Date of Termination
(If apprc")
1. Committee Information
NAME OF COMMITTEE
y 4t~NC
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STREETADDRESS (NO P.O. BOX)
IV144
FAX / E-MAIL ADDRESS
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
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Attach additional intormation on appropriately labeled continuation sheets.
Y
vasurer and Other Principal
ME OF TREASURER
Z~y ~R
REETADD SS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODEIPHONE
CITY STATE ZIP CODE AREA CODEIPHONE
3. Verification
I have used all reasonable diligence in preparing this statement and to the hest of my knowledge the information contained herein is true and complete. I certify under penalty of
peduiy under the laws tl~e 77i~ California that the foregoing is true and cored
Executed on By '/j( 4 , ( S1 RE URER OR ASSISTANT TREASURER
Executed on DAIE By. J-1 - SIGNATURE OF CQNIROLUNG OFFICEHOLDER. CANDIDATE, STATE MEASURE PROPONENT
Executed on
DATE
Executed on
DATE
By
CONTROLLING
-9116MURE OF FPPC Form 410 (June/09)
FPPC Tait-Free Helpline: 866/ASK-FPPC (866/275-9772)
By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
STATEMENT OF ORGANIZATION
Page 2
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4. Type of Committee Complete the applicable sections.
• 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 "non-partisan'
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
,!),#Y/.r> Co
G IT O Ale/L W A
Non-Partisan
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❑ Non-Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION VAREACODEIPHONE BANK ACCOUNT NUMULK
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ADDRESS CITY STATE ZIP CODE
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 MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
FPPC Form 410 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
16
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
STATEMENT OF ORGANIZATION
3
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4. Type of Committee (continued)
Genetal • Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee
PROVI BRIEF DESCRIPTION OF ACTIVITY
• . . . List additional sponsors on an attachment.
NAME /OF ONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
/Y
STRE ADDRESS NO. AND STREET CITY STATE ZIP CODE
Date qualified
5. Termination Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent certify that all of the following conditions have been met:
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 officers who are leaving office and by defeated candidates. Refer to
Government Code Section 89519.
- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511 -
89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410 (June/09)
FPPC Toll-Free Helpline: 8661ASK-FPPC (866/275-3772)