Form 410 Amendment Cl T Y CI :
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Statement of Organization Date:tam, a.
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Recipient Committee ,..J/ •
Statement Type Initial ICJ Amendment ❑ TemslnaHon-See Pad For Official Use only
Not yet qualaic4❑ or Dstl D.number: List l.O.number.
e 1389886 p
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Datequall0edascommlaee DEPEequalMedas committee Oarsof Termination
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1. committee Information 2. Treasurer and Other Principal Officers
rrN--AAAME OF COMMITTEEEy —1
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STREET ADDRESS(No!d.I
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CITY STATE EIP CODE AREA COOUPNONE NAME Or ASSISTANT TRfASU0.EIE If ANY
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MAXIMG ADDRESS If oIffFPENT) STRE[
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RAVE MAXADDRESS Lm STATE Em CODE AREA COOU.NOVE
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COUNTYOT Do"ULF IUMSOICTIOMWXfpf COMMITTfEISACTIVE NAME OE VMNOPAL OFFICOUE)
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ZIP CODE AAEP COOF/➢XONL
Attach additional information on appropriately labeled contlnuanon sheets. O
EnCir1\TT45 CA 12.DZ4 M-38Z- 370
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 Stat alifornla /r,/qpe foregoing is true and correct.
ExecUted on q-14- 20/b BY_�
AF� �/ �S I4XATU0.l Of tRfASUPER Op A1115TAMi T0.LASVREp
Executed on �r{oA �lJ(3 BY_ ///1
TE J SIGHPTUPEOP GO ff ICEXOCDE0..[AXOIOAi OR STMf MEASURE PpOPONf NT
Executed on By
.All NUENATURE Of CONTROLL NO orncENOLOER,CANOIDATE,OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNPNRE Of CONTROLLING OrXCENOLOER,CANOIDATE,OR STATE MEASURE PROPONENT
FPPC Form eta pan/20361
I Advice:advicelgiippe.ca.gov 1866/275-37721
www.fppc.ca.goi,
Statement of Organization
Recipient Committee •
INSTRUCTIONS ON REVERSE
PryBx
Cc..ITTEE XPME XUMBM
Coyvm: }te OQ I -40 rv"C%nz}as pkcosuvtn T 1389886
• All committees must lln the financial Institution where the campaign bank sucturr:is located.
XPME OF nNAVCULIXSTRVTION .LPFALODF/"OF BPNA RICO V NET NV V B ER
Chase F�a�t� (760) 633- 4814 872063271
ADDRESS CITY STATE ER COOS
l05 N, EI G VAa tl0 P.cil/ CLnG P1i}0.5 CA 2-0 2R1
4.Type of Committee Complete the applicable sections.
• List the name of each controlling officeholder,candidate,or state measure proponent. If candidate or officeholder wntrolied,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"nonpartisan."
• If this committee acts jointly with another controlled committee,list the name and identification number of the other controlled committee.
ELE51 CTIVE OFFICE 5 OR HELD
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROP ON ENT UMCLUDE DISTRICT NUM BE R IF APPLICABLEi YEAR OF ELECTION PARTY
❑Nonpartisan
❑Nonpartizan
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATfISI NAME OR MEASUBEISI FULLTITLE(INCLUDE BALLOT NO OR LETTER) CANOIOATEISI OFFICE SOUGHT OR HELD OR MEASUREISI JURISDICTION
IINCLU DE DISTRICT NO.,CITY OR COUNTY,AS APPLICABLE) CHfLCONE
SUPPORT OPPOSE
Meo.socc T ClAry eF EtnC%vN%i-c.s
F❑ I °a
FPPC Form 41011an/20161
FPPC Advice:advicetifppc.ca.gsw 1666/275a7721
www.b,Pc.ta.gov
Statement of Organization • ' ,
Recipient Committee a
INSTRUCTIONS ON REVERSE
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[DMMITiEF N+MF L,uu� ,D.NUMlFI1
COMmi'k}CC d Se-c� '�o �G\tlll A-R5` CC I 1384886
4.Type of Committee (connnued)
Not formed to support or oppose speclflc candidates or measures in a single election. Check only one boa:
❑CITY Committee []COUNTY Committee❑STATE Committee
IIIMIDE(RIFF DFSIAIrtIDN Of/.RIVIn
List additional sponsors on an attachment.
upMEDnroxsD+ INDUSTRr csaui 01011111110"of SPONSOR
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S.Termination Requirements By stnKg the vedit•tim.Me mea sure,esskrant tvasuwr sEWx c•ndYlate.officeholder.or Prorwnent oerdfy that en of the fi Nkk n<condimns hwe 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 maybe used for political,legislative or governmental purposes under Government Code Sections 89511-895 18,and are
subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410(Jan/2016)
FPPC Advice:advice @fppc.u.gov(866/275-37721
www.fppc.ca.gov