HomeMy WebLinkAboutBPPAC FORM410 Statement of Organization
Recipient Committee
Statement Type Initial
Not yet qualified F1 or
Dale qualified as committee
1. Committee Information
OF COMMITTEE
STREET ADDRESS(NO PO.BOX)
Type or print In ink
Amendment
List I.D. number.
9y3y9 z
Date qualified as Committee
(iI W,�)
❑ Termination—See Part 5
List I.D. number
CITY STATE ZIPCODE AREA CODE/PHONE
MAILING ADDRESS(IF DIFFERENT)
OPTIONAL: FAX/E-MAIL ADDRESS
COUNTY OF DOMICILE I COUNTY
THAN CC
IS ACTIVE IF DIFFERENT
Date of Termination
ftr116l �16`�
STAY EM ENT OF ORGANIZATION
04 JAN 29 PM 4:
BAKEI%'Si-iLL,� is I Y QLERK
2. Treasurer and Other Principal Officers
NAME OF TREASURER
_7-4 --1Gs cEa
STREET ADDRESS
CITY STATE ZIP CODE AREA CODEIPHONE
STREET ADDRESS
CITY STATE ZIPCODE AREACODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S),IF APPLICABLE
DOMICILE
MAILING ADDRESS
Attach additional information on appropriately labeled continuation sheets.
CITY STATE ZIP CODE AREA CODEIPHONE
3. Verification
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 certify under penalty of
perjury under the laws of the State of California that the foregoing is true and correct.
Executed on
/- Z % - 0 r/
DATE
SNiNrPURE OF TREASURER OR ASSISTANT TREASURER
Executed on
B,
DA E
SIGNrYURE OF CONTROLLING OFFICEHDLOER,CANdORE.OR STATE MErSIAIE PROPONENT
Executed on
DATE
SIGNRURE OF CONTROLLING OFFICEHOLDER,CANdDRE,OR STATE MEASURE PROPONENT
Executed on
EV
GATE
FPPC Form 410(Jan1(13)
FPPC TnII HalI Mfi/ASK-FPPC