Form 410 Termination 12/21/18 I C
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Statement of Organization D�566 :.03� ���- dl 1 y1 • � � '
Recipient Committee • -
Statement Type ❑Initial ❑ Amendment Terminatlon—See Part 5 2010 DEC 2 1 A1,1 11: � ' For Official Use Only
Q Not yet qualified
or
O Date qualification threshold met Date qualification threshold met Date of termination
1. Committee Information I.D. Number ` q(if aPPlicable) 2. Treasurer and Other Principal Officers
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NAMEOFCOMMITTEE NAME OF TREASURER
ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY
FULL MAILING ADDRESS(IF DIFFERENT) STREET ADDRESS(NO P.O.BOX)
E-MAILADDRESS(REQUIRED)/FAX(OPTIONAL) CITY STATE ZIP CODE AREACODE/PHONE
_fIRA'V Ma Wak a/,-
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(S)
-sue /fro 11117Y ar ii l(lbIiAJ
STREET ADDRESS(NO P.O.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 thi tatement 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 Ca i hat the foregoing is true and correct.
Executed on By r
DATE s NAT RE OF TREASURER OR ASSISTANT TREASURER
Executed on gy
DATF SIGNATURE OF CONTROLLING OFFI OLDER,CANDIDATE,OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT—V 6"L
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT -
FPPC Form 410(AugusV2018)
FPPC Advice:advice @fppc.ca.gov(866/275-3772)
www.fppc.ca.gov