Form 410 Initial 06-17-22CITY OFENCt tC S
CITY cLEAK
2022 JUN 17 PM !
STREET ADDRESS III P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
CITY STATE ZIP CODE COOS/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
p,��qAREA
6 Q
BW��'
FULL MAILING ADDRESS OF DIFFERENT)
STREET ADDRESS (NO P.O. BOX)
E,MAILADDRESS(REED)/ FA�XJOOPPTIONAL)e/m`- �� o
°tea, '� ®� 6 e lam^. y 6@@
CITY STATE ZIP CODE AREA CODE/OPHONE
COUNTY OF DOMICILEp
IU RISDICTION WHERE COMMITTEE IS ACTIVE
NAME OF PRINCIPAL OFFICER(S)
rAttach
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
additional information on appropriately labeled continuation sheets.
I have used all reasonable diligence in preparing tnis statement ano to the nest oT my xnowleage the mTormauun GUnLOIneU I1tl1 Z11I IJ LI U, cnu IINI-«. I y wlucl
penalty of perjury under the laws of the State of California that the foregoing is true and correct. r
Executed on & A— �� ® By
GATE SIGNATURE Oi EASURERO ASSISTANT TREASURER
Executed on � B* x"
DATE SIGNATURE OF CONTROLLING OFFICEHOLDERS CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (August/2O18)
FPPC Advice: pdvice gc.ca.ggy(866/275-3772)
www.fggc.ca.egv
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
NAME
W
• All committees must list the financial institution where the campaign bank account is located.
Page 2
I.D. NUMBER
NAME OF FINANCIAL INSTITUTION AREA
A;®CODE/PHONE 0BANK ACCOUNT NUMBER �" a
ADDRESS ® , lCITY STAT� ZIP CODE?�
k I
d
,r.. , ate• , >,M� � -� ,�. ,..7zrs,�4 ...1. _ a� . ,... , .. > M,.x, ,...,
• 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 "nonpartisan." Stating "No party preference" is acceptable.
• 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 YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION CHECK ONE
Nonpartisan
Partisan
(list political party below)
Wfyl
Nonpartisan
Partisan
(list political party below)
,Primarily Formed committee 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)
IF A RECALL STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT
---SUPPORT
OPPOSE
OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
4,s Not formed to sup
port or oppose specific candidates or measures in a single election. Check only one box:
® CITY Committee ® COUNTY Committee ❑ STATE Committee
PROVIDE BRIEF DESCRIPTION OFACTIVITY
List additional sponsors on an attachment.
OR AFFILIATION OF SPONSOR
NO. AND STREET CITY
Page 3
ZIP CODE AREA
Small Conlributoi Commltte2This committee has ceased to receive contributions and make expenditures;
,�-,.�J' �l'�Yn1117r']�?i'CJ�1'���jUIIP��f1�'F1'�� 9ys�gnirjgEh�vePifitah+Yfi,thB�rir�surer,�ssisY'�lttr�as�ir�r�nd/oriandi�iahr offic�3t�ltler>oPpofi�t,tiertifytHetaYla'Fthefdllaov3n�+conrfjboltsl{avebg�nmet
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 may be used for political, legislative or governmental purposes under Government Code Sections 89511-
89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18S21.5.
FPPC Form 410 (August/2018)
FPPC Advice: advicetafopc.ca.eoV (866/275-3772)
wwwS C.ca.eOV