Form 410 AmendmentStatement of Organization
Recipient Committee
Statement Type ❑ Initial
Not yet qualified ❑ or
1.
Date qualified as committee
Type or print in ink
® Amendment
List I.D. number
1349104
11 / 12
Date qualified as committee
(If applicable)
%,ommittee Information
NAME OF COMMITTEE
Kevin Forrester for Encinitas City Council 2012
❑ Termination — See Part 5
List I.D number
STREETADDRESS (NO PO BOX)
4403 Manchester Ave Ste.205
CITY STATE ZIP CODE AREA CODE/PHONE
Encinitas CA 92024 760- 944 -1918
MAILING ADDRESS (IF DIFFERENT)
PO Box 448 Oceanside, CA 92049
OPTIONAL: FAX / E- MAILADDRESS
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
San Diego
Attach additional information on appropriately labeled continuation sheets.
/ —J
Date Of Termination
Stamp
CITY OF ENCINITA
CITY CLER0,
2012 AUG 20 AM 10' 5
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Mary E Azevedo
STREET ADDRESS (NO P.O BOX)
STATEMENT OF ORGANIZATION
For Official Use
1734 S Pacific Street
CITY
STATE ZIP CODE AREA CODE /PHONE
Oceanside CA 92054 760- 439 -5979
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF PRINCIPAL OFFICER(S)
STREETADDRESS (NO P.O BOX)
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 t State of California that the foregoing is true and correct.
Executed on 12- By
8 � > �SIGNRERER OR ASSISTANT TREASURER
Executed on C_�
DATE By
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 PROPONEN
FPPC Form 410 (April /2011)
FPPC Toll -Free Helpline. 866 /ASK -FPPC (866/275 -3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Kevin Forrester for Encinitas City Council 2012
4. Type of Committee Complete the applicable sections.
Controlled Committee
STATEMENT OF ORGANIZATION
I.D. NUMBER
1349104
• 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
NAME OF CANDIDATE/OFFICEHOLDER /STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
Kevin K. Forrester ® Non - Partisan
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 AREACODE/PHONE BANK ACCOUNT NUMBER
Union Bank, N.A. 760 - 722 -1631 0020622911
ADDRESS CITY
STATE ZIP CODE
840 South Coast Hwy Oceanside CA 92054
• @ • 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) CHECK ONE
FPPC Form 410 (April /2011)
FPPC Toll -Free Helpline 866 /ASK -FPPC (866/275 -3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
rvmmc
STATEMENT OF ORGANIZATION
I.D. NUMBER
Kevin Forrester for Encinitas City Council 2012 1349104
4. Type of Committee (Continued)
• • 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.
.-C yr 0ru1VJVK
STREET
Small Contributor Committee �
Date qualified
&I I W,
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
ZIP CODE
5. Termination Requirements By signing the verification, the treasurer, assistant treasurer and /or candidate, officeholder, or proponent certify that all of the following conditions have been met:
• 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
-- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511 -
89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521 5
FPPC Form 410 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)