Form 410 Termination 12/17/2016Statement of Organization
Recipient Committee
Statement Type ❑ initial ❑ Amendment
Notyetquaifted ❑ or List l.D.number:
® Termination — See Part 5
List I.D. number:
# 1380766
12' 17 / 2016
Date qualified as committee Date qualified as committee Date of Termination
(If applkable)
Date Stamp
r
L
Page 1 of 3
1. Committee Information 2. Treasurer and Other Principal Officers
NAME OF COMMITTEE NAME OF TREASURER
Tasha Boerner Horvath for Council 2016 Simon Mayeski
STREET ADDRESS (NO P.O. BOX) STREET ADDRESS (NO P.O. BOX)
For Official Use Only
315 S. Coast Hwy Ste # U -81 11152 Portobelo Dr
CITY STATE ZIP CODE AREA CODE /PHONE CITY STATE ZIP CODE AREA CODE /PHONE
Encinitas CA 92024 760- 274 -4905 San Diego CA 92124 858 - 361 -8223
MAILING ADDRESS (IF DIFFERENT) NAME OF ASSISTANT TREASURER, IF ANY
315 S. Coast Hwy Ste # U -81 Encinitas, CA 92024
FAX / E -MAIL ADDRESS STREET ADDRESS (NO P.O. BOX)
simon @mayeski.com
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
San Diego I San Dieoo
Attach additional information on appropriately labeled continuation sheets.
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIPCODE AREA CODE /PHONE
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the informa �' co �ed 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. l i / ,7//a ,, l'
Executed on 12/17/2016 By Simon Ma eski /1" 7V
DATE SIGNATURE OF TREASURER OR ASSISTANT THE SU ER
Executed on 12/17/2016 By Tasha Boemer Horvath / e
GATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STAT SURE PROPONE
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on
DATE
Bfreel F®1e
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By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (Dec /2012)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov