Roland Velasco - Form 410 - 2017 AmendmentStatement of Organization
Recipient Committee
Statement Type ❑ Initial
0 Not yet qualified
or
0 Date qualified as committee
1. Committee Information
NAME OF COMMITTEE
[?01 + -J
Amendment
/ — /
Date qualified as committee
(If arrsnding to provide this date)
❑ Termination — See Part 5
— / /
Date of termination
Tya
LO
NOV - 9 2017
I.D. r1Jumber if applicable) 2. Treasurer and Other Principal Officers
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STREET ADDRESS (NO P.O. BOX)
CITY f STATE ZIP CODE AREA CODE /PHONE
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MAILING ADDRESS (IF DIFFERENT)
E -MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL)
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COUNTY OF DOMICILE I JURISDICTIONWHFRF [ nM T- FKACrl-
For Official Use Only
NAME OF TREASURER
A&L
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
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NAME OF ASSISTANT TREAVRER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
Attach additional information on appropriately labeled continuation sheets. CITY
STATE ZIP CODE AREA CODE /PHONE
3. Wr 'eatibn -
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 laws of the State of California that the foregoing is true and correct.
Executed on By
TE
Executed on FZ/? By
DATE
SIGNATURE OF TREASURER OR
OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (May /2017)
FPPC Advice: advice@fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Statement of Organization • -
Recipient Committee • -
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME ga-41qd /` �.J r` 01411c) ' 26 20 — ID NUMBER
• All committees must list the financial institution where the campaign bank account Is located.
NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER
�4-'11 k I L(0�- �2 -,Id2CO 2
ADDRESS CITY STATE ZIPCODE
Ala
4: TVae of7Coinmittee- `ComDiete�the ati icable 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 of candidate is affiliated or check "nonpartisan."
• 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
NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPOIJENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
` - DL+'1'!`if:` �f��$L.�
� �. �� /` � 1 ✓'�/
��
onpartisan
El
❑ Nonpartisan
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATEW OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
CANDIDATEIS) NAME OR MEASUREIS) FULL TITLE (INCLUDE BALLOT NO OR LETTER)
(INCLUDE DISTRICT NO, CITY OR COUNTY, AS APPLICABLE) CHECK ONE
FPPC Form 410 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
SUPPORT
OPPOSE
El
1:1
SUPPORT
OPPOSE
_
FPPC Form 410 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 3
NAME /^
�
ID NUMBER
393
of Committee (Continued)
General Pur • • Not formed to support or oppose specific candidates or measures,in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
• • List additional sponsors on an attachment.
NAME OF SPONSOR JINDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO AND STREET CITY STATE ZIP CODE AREA CODE /PHONE
._SmalhCont�ib.ut6rZ6!�mittee NJ
Date qualified
S. 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: J
• 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.
-- 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 18521.5.
FPPC Form 410 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
yStatement Type ❑ Initial
Q Not yet qualified
or
O Date qualified as committee
Amendment
Date qualified as committee
(If amending to provide this date)
1. Committee Information I.D. Number
❑ Termination — See Part 5
Date of termination
NAME OF COMMITTEE
STREET ADDRESS (NO P.O. BBOOX)�
k
t v auuc L UWE AREA CODE /PHONE
MAILING ADDRESS (IF DIFtERENT)
E-MAIL ADDRESS ((RREEQUIUUIRED) / FAX(OPTIONAL)A,
COUNTY OF DOMICILE
JURISDICTIO ;RE COMV y
Date Stamp
R DE {liED AND FILE
in ti off(ce of the Secretary of Sta
of the State of California
NOV 13 2017
2. Treasurer and Other Principal Officers
For Official Use Only
NAME OF TREASURER
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF PRINCIPAL OFFICERS)
STREET ADDRESS (NO P.O. BOX)
Attach additional information on appropriately labeled continuation sheets. CITY
STATE ZIP CODE AREA CODE /PHONE
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 laws of the State of California that the foregoing is true and correct.
Executed on By
TE 2 SIGNATURE OF TREASURER OR ASSISTANT TREASURER
Executed on 7 By
DATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE
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 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Statement of Organization CALIFORNIA
•Recipient Committee FORM
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME ga-ANJ I.D. NUMBER
Jg� / I�V it ' 26 20 -39 -�, ?Y
• All committees must list the financial institution where the campaign bank account is located
NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER
ADDRE55 CITY STATE 21P CODE
4. Type of Committee Complete the api4licable 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 "nonpartisan."
• 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
NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPONENT
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE CANDIDATE(5) OFFICE SOUGHT OR HELD OR MEA5URE(S) JURISDICTION S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) (INCLUDE DISTRICT NO.. CITY OR COUNTY, AS APPLICABLE)
SUPPORT
onpartisan
❑ Nonpartisan
Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE CANDIDATE(5) OFFICE SOUGHT OR HELD OR MEA5URE(S) JURISDICTION S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) (INCLUDE DISTRICT NO.. CITY OR COUNTY, AS APPLICABLE)
FPPC Form 410 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
SUPPORT
OPPOSE
SUPPORT
OPPOSE
El
El
FPPC Form 410 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Statement of Organization
.Recipient Committee
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME �^ � � � �
I.D. NUMBER
_
4 vp& , , * -�e (continued)
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
CITY
GROUP OR AFFILIATION OF SPONSOR
STATE ZIP CODE AREA CODE /PHONE
Contributor Small I
Date qualified
5. Termination Requirements By signing the verification, the treasurer, assistant treasurer and /or candidate, officeholder, or proponent certify that all oft he 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.
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 18521.5.
FPPC Form 410 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Statement of Organization Date Stamp
Recipient Committee ~ ti
State
4
•
fth
Statement TY0 ❑ Initial Amendment ❑ Termination — See Part 5 Of I For Official Use Only
0 Not yet qualified
c=17 or
0 Date qualified as committee
Date qLI flified as committee Date of termination
(If amen 'ing to provide this date)
Committee information I.D. Number if applicable) G 2. Treasurer and Other Principal Officers
_q
NAME OF COMMITTEE NAME OF TREASURER
STREET ADDRESS (NO P.O. BOX)
J �
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
C)
C)p Est �� 4
CITY V STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREAJURER, IF ANY
/P V 20
MAILING ADDRESS (IF DIFVERENT) STREET ADDRESS (NO P.O. BOX)
E-MAIL ADDRESS (REQUIRED)/ FAX (OPTIONAL) CITY STATE ZIP CODE AREA CODE/PHONE
COUNTY OF DOMICILE JURISDICTIO WHERE 1. �ito
C07r TEE YS VE NAME OF PRINCIPAL OFFICER(S)
S - �l v
STREET ADDRESS (NO P.O. BOX)
Attach additional information on appropriately labeled continuation sheets. CITY STATE ZIP CODE AREA CODE /PHONE
9. Verification
I have used all reasonable diligence in preparing this st,)tement and to the best of my knowledge the information contained herein i I s true and complete. I certify under
penalty of perjury under the laws of the State of Calif PIR that the forego is true and correct.
-;k%
Executed on 6 By
a GNATURE OF TREASURER OR ASSISTANT TREASURER
LzExecuted on Z? 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 (May/2017)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization • - '
Recipient Committee • -
INSTRUCTIONS ON REVERSE
• Page 2
COMMITTEE NAME I.D. NUMBER
26 ZO
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER
ifoatAc"' -?te 1 J6 _5 -7
ADDRESS CITY STATE ZIP CODE
L<. �' & C 64 gi5b M
• 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."
• 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
NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
(mat- Loam
OR
- �t 6 //fl' I/
(N lJ >
04Lonpartisan
SUPPORT
❑ Nonpartisan
Primarily • • Committee Primarily formed to support or oppose specific candidates or measures in a single election. list below:
CANDIDATE(S) NAME OR MEASURES) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATES) OFFICE SOUGHT OR HELD OR MEASURES) JURISDICTION
(INCLUDE DISTRICT NO.. CITY OR COUNTY, AS APPLICABLE) ruarit nNv
FPPC Form 410 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
SUPPORT
OPPOSE
SUPPORT
OPPOSE
❑
❑
FPPC Form 410 (May /2017)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov