Form 41075-11
Statement of Organization
Recipient Committee
Statement Type @ Initial
Not yet qualified ® or
_f-i
Date qualified as committee
STATEMENT OF ORGANIZATION
Type or print in ink Date Stamp
CI11 OF E CINITAS
t "nprFWK
List LD number
2012~UG -7 PPS 3: 27
Date qualified as committee
(If applicable)
0 Termination -See Part $1 the 's✓c- } I , Of State For Official Use Only
List I D number, t the _ I
Date of Termination
1. Committee Information
NAME OF COMMITTEE
Kevin Forrester for Encinitas City Council 2012
STREET ADDRESS (NO PO BOX)
4403 Manchester Ave Ste 205
CITY STATE ZIP CODE AREA CODE/PHONE
Encintas CA 92024 760-944-1918
MAILING ADDRESS (IF DIFFERENT)
PO Box 448 Oceanside CA 92049
OPTIONAL. FAX/ E-MAIL ADDRESS
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
San Diego
Attach additional information on appropriately labeled continuation sheets
JUL 2 7 2012
EBR bOWEN
~cretary of Mate
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Mary E Azevedo
STREET ADDRESS
1734 S Pacific St
CITY
Ocenside
STATE
CA
ZIP CODE
92054
AREA CODE/PHONE
760-439-5979
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/PHONE
NAMEAND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
MAILING ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/PHONE
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 `~I; By
~J DATE SIG E OF TR SURER OR ASSISTANT TREASURER
Executed on / By 4t_Af.~"~
DATE TURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on
DATE
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline 866/ASK-FPPC (866/275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
WMITTEE NAME
Kevin Forrester for Encinitas City Council 2012
LD
4. Type of Committee Complete the applicable sections.
Controlled Committee ,
• 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 OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
® Non-Partisan
Kevin K. Forrester
Encinitas City Council Member
2012
❑ Non-Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION
ADDRESS
AREA CODE/PHONE
CITY
BANK ACCOUNT NUMBER
STATE ZIP CODE
Primarily Formed Committee 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)
OF
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
O
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)