Form 410 Termination Statement of Organization Type or print in ink
Recipient Committee
Statement Type ❑Initial ❑ Amendment
Not yet qualified ❑ or List LD number
Date qualified as committee Date qualified as committee
(If applicable)
® Termination—See Part 5
List LID number
#1349104
12 31 12
1. Committee Information
NAME OF COMMITTEE
Kevin Forrester for Encinitas City Council 2012
STREET ADDRESS(NO RID 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-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
Date of Termination
Date Stamp
TY OF MCINITAS
CITY CLEr?.,,
3 JAN 31 AM 11: 36
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Mary E.Azevedo
STATEMENT OF ORGANIZATION
For
STREET ADDRESS(NO PO BOX)
1734 S Pacific Street
CITY STATE ZIP CODE AREACODE/PHONE
Oceanside CA 92054 760-439-5979
NAME OF ASSISTANT TREASURER,IF ANY
STREETADDRESS(NO PO BOX)
CITY STATE ZIP CODE AREACODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS(NO PO BOX)
CITY STATE ZIP CODE AREACODE/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 al '
Executed on 3� 13 By
ATE
Executed on ` By
DATE
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(April/2011)
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