Form 410 Termination 12/19/12 Statement of Organization
Recipient Committee
Statement Type ❑Initial
Not yet qualified ❑ or
I I
Date qualified as committee
1. Committee Information
NAME OF COMMITTEE
Shaffer for Council 2012
STREET ADDRESS(NO PO BOX)
Type or print in ink
❑ Amendment
List ID number-
Date qualified as committee
(If applicable)
® Termination–See Part 5
List LD number,
# 1340286
12 1 19 t 12
Date of
62
CITY STATE ZIP CODE AREA CODE/PHONE
Encinitas CA 92024
MAILING ADDRESS(IF DIFFERENT)
OPTIONAL. FAX/E-MAIL ADDRESS
STATEMENT OF ORGANIZATION
ate Stamp
CI Y OF Fi`dCli
CITY fr
2012 DEC 19 PH 0 10
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Lisa Shaffer
STREETADDRESS(NO PO
ITY STATE ZIP CODE AREA CODE/PHONE
Encinitas CA 92024
NAME OF ASSISTANT TREASURER,IF ANY
STREET ADDRESS(NO PO.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
COUNTY OF DOMICILE I COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE STREET ADDRESS(NO PO.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
Attach additional information on appropriately labeled continuation sheets.
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herei 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 ( LI I l 1 12— B y �"
DATE , I J, SIGN,TU REASU AR ASSISTANT TREASURER
Executed on By
DATE
Executed on
DATE
Executed on
DATE
OR STATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT
FPPC Form 410 (April/2011)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)