AFSCME - Form 410 2013Statement of Organizationl._
Recipient Committee - -- - ' "'`
Statement Type ❑ Initial Amendment
Not yet qualified ❑ or List I.D. number:
# 821697
Date qualified as committee Date qualified as committee
(If applicable)
1. Committee Information
NAME OF COMMITTEE
AFSCME Local 101 AFL -CIO PAC
❑ Termination — See Part 5
List I.D. number:
_I I
Date of Termination
STREET ADDRESS (NO P.O. BOX)
1150 N. First Street
CITY STATE ZIP CODE AREA CODEIPHONE
San Jose CA 95112
MAILING ADDRESS (IF DIFFERENT)
OPTIONAL: FAX/ E -MAIL ADDRESS
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
SANTA CLARA
Attach additional information on appropriately labeled continuation sheets
` �iDate/S�tamp ®O"
SEP 2013
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2. Treasurer and Other Principal- Officers
NAME OF TREASURER
Elizabeth Bettencourt
STATEMENT OF ORGANIZATION
For Official Use
STREET ADDRESS
5028 Chiles Court
CITY STATE ZIP CODE AREA CODE/PHONE
San Jose CA 95136 408 - 293 -6302
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE
3. Verification
I have used all reasonable diligence in preparing this statement and to the
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
Executed on
By
DATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (January/05)
FPPC Toll -Free Helpline: 866 1ASK -FPPC (866/275 -3772)
Statement of Organization STATEMENT OF
Recipient Committee CALIFORN,
.-
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D. NUMBER
AFSCNIE LOCAL 101 AFL -CIO PAC 821697
4. Type of Committee Complete the applicable sections.
• 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 "non- partisan."
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CANDIDATE /OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION
ADDRESS
I AREA CODE/PHONE
CITY
ACCOUNT NUMBER
STATE ZIP CODE
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)
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION,
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
OPPOSE
FPPC Form 410 (January/05)
FPPC Toll -Free Helpline: 866/ASK -FPPC (866/275 -3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
AFSCME LOCAL 101 AFL -CIO PAC
4. Type of Committee (Continued)
General Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee
' • ' • • List additional sponsors on an attachment.
--mm ur arurvavrc INDUSTRY GROUP ORAFFILIATION OF SPONSOR
AFSCME LABOR UNION
--- — rv". Hrvu a 1 Krt i CITY STATE ZIP
STATEMENT OF ORGANIZATION
Page 3
821697
80 SWAN WAY OAKLAND CA 94621
❑ —�_ Check box and provide the date this committee qualified as a small contributor committee. If the committee qualified as a
Date qualified small contributor committee on January 1, 2001, enter 1/1/01.
5.Termination Requirements By signing the verification, the treasurer, assistant treasurer and /or candidate, officeholder, or proponent certify that all of the following conditions have 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.
FPPC Form 410 (January/05)
FPPC Toll -Free Helpline: 866 /ASK.FPPC (866/275 -3772)
Instructions for
Statement of Organization
Sponsored Committee
A "sponsored committee" is a general purpose or
primarily formed committee, other than an
officeholder or candidate controlled committee, that
has one or more sponsors.
An organization, business, or other entity is a
sponsor if one or more of the following apply:
• The committee receives 80% or more of its
contributions from the entity or organization or its
members, officers, employees, or shareholders.
• The entity or organization collects contributions
for the committee by use of payroll deductions or
dues from its members, officers or employees.
• The entity or organization, alone or in
combination with other entities or organizations,
provides all or nearly all of the administrative
services for the committee.
• The entity or organization, alone or in
combination with other entities or organizations,
sets the policies for contribution solicitations or
payment of expenditures from committee funds.
See the instructions for Part 1 for name
identification requirements.
Small Contributor Committee
A "small contributor committee" is one that:
• Has been in existence for more than six months;
• Receives contributions from 100 or more
persons;
• Makes contributions to five or more candidates;
and
• Has not received more than $200 from one
person in a calendar year.
See FPPC Regulation 18503.
5. Termination Requirements
Recipient committees do not automatically
terminate; they may only terminate under the
following circumstances:
• They have ceased to receive contributions and
make expenditures; and
• They do not anticipate receiving contributions,
repayments of outstanding loans made to others,
or any other receipts in the future, and they do
not anticipate making expenditures in the future;
and
• They have eliminated or have no intention or
ability to discharge all their debts, loans received,
and other obligations; and
• They have no campaign funds; and
• They have filed all required campaign statements
disclosing all reportable transactions, including
disposition of funds.
State Candidates: There are specific mandatory
termination deadlines applicable to your controlled
committees. See FPPC Campaign Disclosure
Manual 1 for state candidates.
How to Terminate
State Recipient Committees
• File an original and one copy of the Form 410
Statement of Organization Termination along
with an original and one copy of your Form 450
or 460 with the Secretary of State.
• File two copies of your Form 450 or 460 with
your local filing officials.
Local Recipient Committees
• File an original and one copy of the Form 410
Statement of Organization Termination with the
Secretary of State; and
• File a copy of the Form 410 Statement of
Organization Termination, along with an original
and one copy of your Form 450 or 460 with your
filing officer.
FPPC Form 410 (January/05)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)