Form 410 Termination Statement of Organization
Recipient Committee
Statement Type ❑Initial
Not yet qualified ❑ or
Date qualified as committee
1. Committee Information
Type or print In ink
❑ Amendment
List I.D number-
Date qualified as committee
(If applicable)
NAME OF COMMITTEE
J6 41tA Y0,1 t
STREET
' NAME OF ASSISTANT TREASURER,IF ANY
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CITY STATE ZIP CODE AREA CODE/PHONE
STREET ADDRESS
MAILING ADDRESS(IF DIFFERENT)
OPTIONAL. FAX/E-MAIL ADDRESS
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COUNTY QIP DOMICILE
COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
Attach additional information on appropriately labeled continuation sheets.
CITY STATE ZIP CODE AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S),IFAPPLICABLE
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 13i 1 I / 3 By
DATE SIGNATURE OF TREASURER OR ASSISTANT TREASURER
Executed on
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
By
SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME
4.Type of Committee Complete the applicable sections.
ER
OF ORGANIZATION
• 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
• List the financial institution where the campaign bank account is located(controlled"candidate election"committees only)
NAME OF FINANCIAL INSTITUTION
ADDRESS
AREA CODE/PHONE
BANK ACCOUNT NUMBER
CITY STATE ZIP CODE
Primarily Formed Commiftee—; 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)
OPPOSE
FPPC Form 410 (January/06)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)