HomeMy WebLinkAboutDICKERSON 410 2/29/12 AMEND►
Organization,
CITY STATE ZIP CODE AREACODE /PHONE
OPTIONAL: FAX/ E -MAIL ADDRESS
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Pecipient Committee
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COUNTY OF DOMICILE/� COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
u-�r" ' ) THAN COUNTY OF DOMICIILEAw
Statement Type
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CITY STATE ZIP CODE AREA CODE /PHONE
Attach additional information on appropriately labeled continuation sheets.
t I.D. number
List I.D. numi e�'
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contain he I i itaIndcomplete. I certify under penalty of
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Date qualified as committee DW5 of ' .4s`06mmittd'e' Date of Te in ilrkG ;< t
(If applicable)
1. Committee Information
Date
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2. Treasurer and Other Principal Officers
NAME OF COMMITTEE NAME OF TREAS RER
STREET ADDRESS (NO P.O. BOX)
FPPC Form 410 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)
CITY STATE ZIP CODE AREACODE /PHONE
OPTIONAL: FAX/ E -MAIL ADDRESS
NAME OF PRINCIPAL OFFICERS)
COUNTY OF DOMICILE/� COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
u-�r" ' ) THAN COUNTY OF DOMICIILEAw
STREET ADDRESS (NO P.O. BOX)
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CITY STATE ZIP CODE AREA CODE /PHONE
Attach additional information on appropriately labeled continuation sheets.
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contain he I i itaIndcomplete. I certify under penalty of
perjury under the laws of the State of California that the foregoing is true and correct.
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Executed on By
DAT
Sl ATUR O EASURER OR ASSISTANT TREASURER
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Executed on 1i 'By
DATE r
SIGNATURE OF CONTROLLING DER, CAND ATE, OR STATE MEASURE PROPONENT
Executed on By
DATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)
STATEMENT OF ORGANIZATION
Statement of Organization , CALIFORNIA
Recipient Committee FORM 4
INSTRUCTIONS ON REVERSE Page 2
I.D. NUMBER
COMMITTEE NAME Cr5f A N l c� i >� �1 2
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 Or r.ANrnnATFinFFICFHOLOER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FIf ANCIAL INSTITUTION
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
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SUPPORT OPPOSE
FPPC Form 410 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
STATEMENT OF ORGANIZATION
COMMITTEE NAME ^ C I.�
4. Type of Committee (Continued)
General Purpose 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
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored . List additional sponsors on an attachment.
NAME OF SPONSOR
STREET
CITY
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
ZIP WDE:
❑ __J_ 1
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 (April /2011)
FPPC Toll -Free Helpline: 866,ASK -FPPC (8661275 -3772)