HomeMy WebLinkAboutBFLAG 410 AMEND 7/01/01 tatement of Organization
Recipient Committee
Type or print in ink
Date Stamp
STATEMENT OF ORGANIZATION
Statement Type [] Initial
Not yet qualified [] or
__J I
Date qualified as committee
1. Committee Information
~/Amendment [] Termination - See Part 5
List I.D. number. List I.D, number. 0 ]
Date qualified as committee Date of Termination
STREET ADDRESS (NO P.O. BOX)
.
MAILING ADDRESS (iF DIFFERENT}
STATE ZIP CODE AREA CODE/PHONE
30 PH 2:17
(SFIEL.D CITY CLERK
2. Treasurer and Other Principal Officers
For Official Use Only
NAME OF TREASURE~,'~.~J ~--~ t k\ '
MAILING ADDRESS
CITY
NAME OF ASSISTANT TREASURER, IF ANY
MAILING ADDRESS
STATE ZIP CODE AREA CODE/PHONE
(;a q5'5c t,8'F2. za5'¢-
OPTIONAL: FAX / E-MAIL ADDRESS
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
~__.. ~_j~ THAN COUNTY OF DOMICILE
Atlach additional information on approp#ately labeled continuation sheets.
CITY
NAME AND POSITION OF OTHER PRINCIPAL OFFICEI~(S), IF APPLICABLE
~ILING ADDRESS /
CI~ STATE ZIP CODE
STATE ZIP CODE AREA CODE/PHONE
AREA CODE/PHONE
~fz -O 75 7'
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. ~ ~)~1/~
Executed on By ! X"x~,.~/\ ~ ~ , /
Exac~eUon '7 / OI ~
DA~ SIGNATURE OF CON~OLLING OFFICEH~DER, CANDIDATE, OR STATE MEASURE PROPONENT
Exec~ ~ ~
DATE SIGNATURE OF CONTROtLING OFFICEHOLDER. CANDIDATE, OR STATE MEASURE PROPONENT
Exe~ on ~
FPPC Form 410 (8/99)
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 2
.D. NUMBER
4. Type of Committee Complete the applicable sections.
· List lhe 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 OB HELD
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PART?
[] Non-Partisan
[] Non-Partisan
· List the financial institution and the disposition of surplus funds (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION
AREACODE/PHONE
BANKACCOUNTNUMBER
DATE OPENED
ADDRESS CITY STATE ZIP CODE DISPOSITION OF SURPLUS FUNDS
I~,l~m~.l~,~.7,.;~,,';~,.~,l~li~II~:~ 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)
SUPPORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410 (8/99)
For Technical Assistance: 916/322-5660
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
STATEMENT OF ORGANIT, ATION
I.D. NUMBER
4. Type of Committee {Continued)
l~=~r~xl=~lt'x°~-~r=~r,~-~-~*l~'-~ 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
List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
MAILING ADDRESS NO. AND STREET CITY STATE ZIP CODE
~ [] (For purposes of special election contribution limits)
5. Termination
· This committee
· This committee
· This committee
· This committee
· This committee
has ceased to receive contributions and make expenditures;
does not anticipate receiving contributions or making expenditures in the future;
has eliminated or has no intention or ability to discharge all debts, loans received, and other obligations;
has no surplus funds; and
has filed all campaign statements required by the Political Reform Acl 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
the Information Manual on CamDai(m Disclosure Provisions of the Political Reform Act, for Elected Officers. Candidates and their Controlled Committee~
(Manual A).
-- Additional filing obligations will be incurred if, after terminating, the 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 (8/99)
For Technical Assistance: 916/3~2-5660