Gilroy California Democractic Club - Form 410
355 Qk11
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Type or print in ink
Statement of Organization
Recipient Committee
o Termination - See Pa.fs
ListI.D.number:
o Amendment
List 1.0. number:
I8J initial
Not yet quaified 181 Q(
Statement Type
L\~
#
1--1_
Date of Tel1llination
#
----1 I
Date qualified as committee
(If appicabl8)
11_
Date qualified as committee
NAME OF
Johnella Shackelford
STREET ADDRESS (NO P.O. BOX)
1138 Del Oro Way
CITY
Gilroy
NAME OF ASSISTANT TREASURER. IF ANY
Officers
Other Principal
TREASURER
2. Treasurer and
Committee Information
NAME OF COMMITTEE
Gilroy California Democratic Club
1
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~.) I
ZIP CODE
95020
STATE
Ca
(NO P.O. BOX)
9227 Solana Drive
CITY
S'rReETADDRESS
AREA CODElPHONE
ZIP CODE
95020
STATE
Ca
AREA COOEIPHONE
ZIP CODE
STREET ADDRESS (NO P.O. BOX)
Gilroy
MAILING ADDRESS (IF DIFFERENT)
P.O. Box 410 Gilroy Ca 95021
OPTIONAL: FAX I E-MAIL ADDRESS
STATE
AREA COOE/PHONE
ZIP CODE
95020
STATE
Ca
NAME OF PRINCIPAL OFFICER(S)
Domingo Payne
STREET ADDRESS (NO P.O. BOX)
9227 Solana Drive
~
Gilroy
CITY
COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
COUNTY OF DOMICilE
Santa Clara
Attach additional information on appropriately labeled continuation sheets.
under penalty of
certity
knowledge the infonnation contained herein is true and complete.
Verification
I have used all reasonable diligence in preparing this statement and to the best of my
pe~ury under the laws of the State of California that the foregoing is true and (\t.
Executed on 1/14/2011 By \...~\ (
/'
By f
3.
SIGNATURE OF CONTROLLING OFFICEHOLDER CANOIOATE. OR STATE MEASURE PROPONENT
DATE
Executed on
MEASURE PROPONENT
SIGNATuRE OF CONTROUJNG OFFICEHOlDER. CANDlOATE. OR STATE
By
;re
Executed on
FPPC Form 410 (June/09)
FPPC TolI-Free Helpline: 8661ASK-FPPC (8661275-3772)
By
DATE
Executed on
STATEMENT OF ORGANIZATION
~ ~
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
E NAME
COM
Check only one box:
or measures in a single election.
o STATE Committee
Not formed to support or oppose specific candidates
I8JCITY Committee 0 COUNTY CommittH
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Democratic causes that protect and improve the lives and environment of all Gilroy residents
additional sponsors on an attachment
List
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
ZIP CODE
STATE
CITY
NO. AND STREET
1-
o ~te qualified
STREET ADDRESS
candidate, officeholder, or proponent certify that al of tile following conditions have been met
assislant treasurer and/or
5. T ennination Requirements By signing the verification, the treasurer.
This committee has ceased to receive contributions and make expenditures;
This committee does not anticipate receiving contributions or
making expenditures in the future;
to discharge all debts, loans received, and other obligations;
This ~mmittee has eliminated or has no intention or ability
This committee has no surplus funds; and
Refer to
the Political Reform Act disclosing aU reportable transactions.
held by elected officers who are leaving office and by defeated candidates.
This committee has filed all campaign statements required by
- There are restrictions on the disposition of surplus campaign funds
Government Code Section 89519.
Code Sections 89511
Government
purposes under
- Leftover funds of ballot measure committees may be used for political, legislative or governmental
89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Fonn 410 (June/09)
Helpline: 866/ASK-FPPC (866127S-3n2)
FPPC TolI-F,..