Form 410 Amendment Statement of Organization Dam Stamp
Recipient Committee
Statement Type [3 InMall Amendment ❑ Terinlruatlan—See Part 5 Fm Oftial use Only
Not yet quelled[] Or USE I.D.number: LIST(.D.number.
# 1389864 #_
_-4—If 09' 1(13 12016 _/_.1_
Date qUelffied Sea comma tee Date qualffied as amnardam Dam of TeTTIMOOn
77.7,77;
NAMISOFOCHAMITTIn NAME OF TREASURER
Tony Brandenburg for Encinitas City Council 2016 Kevin K Forrester
STREET ADDRESS BID RA.BOX)
Encinitas CA 92024 760-944-1918
an STATE aPOODE AREA,COGvFNoYE NAME OF ASSISTANT TREASURE',IF MY
Encinitas CA 92024 760-944-1918
MANIW ADDRESS(IF DIFFERENT) STREET ADDRESS(NO P.O.BOX)
CITY STAN DPOODE AREACODVPHONE
kforrester@psmkr.us
COUNTYWOOMPOLE JURNORMON WHERE OOM berm 15 ACTIVE NAME OF PRINODUL OFWERD)
San Diego County lCity of Encinitas Anthony J. Brandenburg
STRFETADDRE55INO PA.BON)
On STATE ZIPMDE ARM CODEPHONE
Attach additional information on appropriately labeled continuation sheets. Encinitas CA 92024 760-525-4569
77777777-.7.
I have used all reasonable diligence in preparing this itatt eq nd 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 Callfor 1 the the Vegoing,is true and correct.
Executed on 09/20/2016 — By II
OAT E SRi1UTUBE OF TREASURER 04 ASSISTANT TREASURER
Executed. 09/20/2016 BY
DATE A SIGNATURE OF "NONIATE,OR STATE MEASURE PFOaONMT
Executed ON By
DATE SIGNATURE OF CONIUMUNG OFFIRMHOUDER,CANDIDATE,OR SUDE MEASURE PROPONENT
Exe,auted On By
DATE SIGNATURE OF ONNUKILLING OFFKVIOLDEk CANDIDATE,OR PATE MEASURE PROPONENT FPPC Form 410(Jan/2016)
rPPC Adwica:advica@fppG aa.gov,(866/275-37721
VAVV,Lfpp&CB.IPW