HomeMy WebLinkAboutSALAMACHA SO tatement of Organization
Recilc,;en~, Committee
iGo'ternmen~ Code Sections 84101-84103)
AmeRcement
[] Check box il an Amendment
and ente~' LQ number:
WHERETO FILE:
File original and one copy with:
Type or print in ink SecretaP/ol State
Political Relorm Diwsion
PO Rox f467
Sacramento. CA 9581271467
If applicable, file one copy with:
The city or county officer, ff any, who receives the
ff committee's odginal campaign disclosure statements
iNSTRUCTIONS ON REVERSE
1. Committee Information
Date Qualified aa Committee
/ /
[~Check box if not yel qualified
NAME OF COMMITTEE
ADDRESS OF COMMI'i-DEE (NOT PO BOX) NO AND STREET
CITY STATE ZIP (~ODE AREA CODFJPHONE NUMBER
CiTY STATE ZIP CODE
AREACOD~PHONENUMBER
STATEMENT OF ORGANIZATION
For Official Use Only
2. Treasurer and Other Principal Officers
NAME OF TREASURER J
MAILING
CITY
STATE ZIP CODE
AREA CODE/DAYTIME PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(SI. IF APPLICABLE
MAILING ADDRESS
CITY STATE ZIP CODE AREA CODEJOAYTIME PHONE
Aflach additfonal information on appropriately labeled continuation sheets
3. Verification
1 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
By
Exec~ on By
DATE SIGNATURE ~ C~TR~UNG OFFICEH~R. C~DI~TE. OR STATE MEASURE P~PONENT
Stat~.ment of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
NAME OF COMMITTEE
4. Type of CommitteE: complete the applicable sections.
STATEMENT OF ORGANIZATION
O NUMBER(IE AMENOMENTt
List the name of each controlling officeholder, candidate, or state measure proponent If candidate or officeholder con~rotled.
also list the elective office sought or held. and district number, if any
· List the political party with which each officeholder or candidate is affilialed An officeholder or candidate not holding or seeking a partisan office must indicate "non-partisan ·
· If this committee acts iointly with another controlled committee, list the name and identification number of the other controlled committee.
· List the disposition of surplus funds
NAME OF CANDIOATE/OFFICEHOLDER/STATE MEASURE PROPONENT
01SPOSITION OF SURPLUS FUNDS:
Not formed to support or oppose specific candidates or measures 3n a singte election. Check only one box: [] CITY Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
[] COUNTY Commfllee
[] STATE Committee
5. Committee Category: Complete one or bolh categories, if applicable.
Provide additional sponsors on an attachment
NAME OF SPONSOR:
MAILING ADDRESS: NO AND STREET
CITY STATE ZIP CODE
Check one, if applicable.
[] Date qualilied as a small confributor committee:
__/ /__
(Month, Day, Year)
FPPC Form 410 (1997)
FofTechnlcal Assistance: 916/322-5660