AFSCME - Form 410 2015 - AmendmentStatement of Organization
Recipient Committee
Statement Type ❑ initial
Not yet qualified ❑ or
Date qualified as commRtee
Type or print In ink
® Amendment
List I.D. number.
* 821697
1._—r
Date qualified as Committee
(K WOW")
STATEMENT OF ORGANIZATION
❑ Termination — See
List I.D. number:
Date of Termination
RECEIVED
.SAN 30 2g15
Y�A OFRM
1. Committee information 2. Treasurer and Ot wcers
NAME OF COMMITTEE NAME OF TREASURER
AFSCME LOCAL 101 PAC
STREUADDRM (NO RO. EIM
1150 NORTH FIRST STREET, SUITE 101
CITY STATE LP CODE AREA CODE/PHONE
SAN JOSE CA 95112 408 -891 -3355
MAILING ADDRESS (IF DIFFERENT)
OPTIONAL: FAX I E4MIL ADDRESS
COUNTY OF DOMICILE COUNTY VA4ERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OFDOMIOLE
Attach additional Wburishon on approprfately labeled conhwaW sheets
ROBYN ZAMORA
STREET ADORERS
1150 NORTH FIRST STREET, SUITE 101
CITY STATE APCODE AREACODEIPHONE
SAN JOSE CA 95112 408-691-3355
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS
CITY STATE LP COME AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFF)CER(S). IF APPLICABLE
MAILING ADDRESS
CITY STATE ZIP CODE AREA CODEIPHONE
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the Information contained herein is true and complete. I certify under penalty of
perjury under the taws of the State of California that the foregoing is true and correct.
Executed on 01 -21 -15 By
DATE
Executed on DATE BY
SIGNATURE OF CONTROLLING OFfICEHIX.OER CANDIDATE, OR STATE MEASURE PROPONENT
Executed on DATE By SIGNATURE OF CONTROLLING OFFICEHOLDER CANDIDATE, OR STATE MEASURE PROPONENT
Executed on BY
OATS SIGNATURE OF CONTROLLANG OFFIEMOLDER. CAND115AM OR IrrATE MEASURE PROPONENT
FPPC Forth 410 (January/"
FPPC Toll -Free Helpline: SMA3K -FPPC (a6W79.3T72)
Statement of Organization STATEMENT OFORGAN17ATION
Recipient Committee CALIFORNIA
FOPNI 410
INSTRUCTIONS ON REVERSE .y p •yY�,
Pape J
COMMITTEE NAME ,+ I.U. NUMBER
AFSCME LOCAL 101 P "7 821697
4. Type of Committee .iced)
PROVIDE BRIEF DESCRIPTION
N ! uppose specific candidates or measures in a single election. Cheok only one box:
CITY o ea ❑ COUNTY Committee [] STATE Committee
List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
AFSCME LOCAL 101 LABOR UNION
STREET ADDRESS NO AND STREET CITY STATE ZIP CODE
1150 NORTH FIRST STREET SAN JOSE CA 95112
0 � I Check box and provide the date this committee qualified as a small contributor committee. If the committee quellf4d as a
Date qualified small contributorcommittee on January 1, 2001, enter 111 /01.
5.Termination Requirements By signIng the verification, the treasurer, assistant treasurer and/cr candidate, officeholder, or proponent cenify that all of the follovAng oonditionshavebeenmet
• This committee has ceased to receive contributions and make expenditures;
This committee Goes 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 fled 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: 3651ASK -FPPC (3661775 -3772)