HomeMy WebLinkAboutTAKII 410 TERMINATION tatement of Organization
Recipient Committee
Statement Type [] Initial
Not yet qualified [] or
1. Committee Information
Type or print in ink
[] Amendment
List I.D. number:
#
Date qualified as committee
(if ~ppl~.e bio )
NAME OF COMMITTEE
STREET ADDRESS (NO RO BOX}
~iTY S~ATE /ZIP CODE ~ ~,~REA CODE/PHONE
~ING ADDRESS (IF DIFFERENT) / ' '
OPTIONAL: FAX / E-MAIL ADDRESS
A~ach addittonal info~a~on on appropriately labeled continuation shoe ts.
3. Verification
iTDerminafion - See Part 5
~ number:
O~
#
Date of Termination
Date Stamp
,... Ir. u C!TY CLERff
2. Treasurer and Other Principal Officers
STATEMENT OF ORGAN)ZATION ,
For Official Use Only
NAME OF TREASURER
STREET ADDRESS
CtTY STATE ZiP CODE
~AME OF ASSISTANT TREASUR~, ~F ANY '
STREET ADDRESS
CITY STATE ZIP CODE AREA CODE'PRONE
NAME AND POSIT~ON OF OTHER PRINC[F~L OFFICER(S), IF APPLICABLE
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I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information conta;ned herein is true and complete. I certify under penalty of
pedury under the laws of the State of California that the foregoing is true and correct.
Executed on
Executed on
Executed on
Executed on
DATE
DATE
DATE
f~ / SIGN~'URE OF CONTROLLING OFFICEHOLDER, CANDIDa'E, OR STATE MEASURE PROPONENT
FPPC Form 410 (Jan/01)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
4. Type of Committee c~mplete the applicable sections.
STATEMENT OF ORGANIZATION
Page 2
I.D. NUMSER
· 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 joinUy with another controlled committee, list the name and identification number of the other controlled committee.
ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDR'E/OFFICENOLDER/STATE MEASURE PROPONENT (iNCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PAR
[] Non-Partisan
· List the financial institution where the campaign bank account Is loceted (controltsd "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION
Primarily formed to support or oppose specific candidates or measures in a single elec~on. 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
(tNCLUDE DISTRICT NO.. CITY OR COUNTY. AS APPLICABLE)
FPPC Form 410 (Janl01)
FPPC Toll. Free H®lpllne: 866/ASK-FPPC
Statement of Organization
Recipient Committee
iNSTRUCTIONS ON REVERSE
4. Type of Committee (Continue~)
STATEMENT OF ORGANIZATION
Page 3
Not formed to suppod or oppos ~ spedfic candidates or measures in a single election. Check onty one box:
[] CITY Committee [~ COUNTY Comrnitlee E~ 8TATECom mittee
PROVIDE BRIEF DESCRIPTION OF AOTIVI~P(
List additions~ sponsors on an attachment.
NAMS OF SPONSOR ~NDUSTRY GROUP OR AFFILFATtON OF SPONSOR
STREET ADDRESS NO AND STREET C)TY STATE ZIP CODE
Date qualified contr~uto¢ committee on Jan uaP/1, 2001, enter 1/1/01.
5. Termination Requirements Bysigningtheveri~cati~n~thetreasurer~ass~st~nttreasurerand/~rcandidate~ceh~der~rpr~p~nentcer[i~y~ata~f~ef~bw~g~ndi~nsh~vebeenmeb
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.
-- Additional filing obligations will be incurred if, after terminating, Be 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 (Jan/01)
FPPC Toll-Free Helpllne: 8661ASK-FPPC