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Fischer, Tom - Form 410 (City Council 2022 - termination)Statement of Organization Recipient Committee Statement Type ❑ Initial ❑ Amendment ® Termination — See Part 5 Not yet qualified ❑ or List I.D. number: List I.D. number: # #1366034 12 /28 2020 Date qualified as committee Date qualified as committee Date of Termination (If applicable) 1: Committee Information f,, NAME OF COMMITTEE Tom Fischer for City Council 2022 STREETADDRESS (NO P.O. BOX) JURISDICTION WHERE COMMITTEE IS ACTIVE Gilroy, CA Attach additional information on appropriately labeled continuation sheets. /,` v DateStam\ For Official Use Only Treasurer and Other Prirrc�parfficers t� x { .ram mat, NAME OF TREASURER Tom Fischer STREET ADDRESS (NO P.O. BOX) NAME OF ASSISTANT TREASURER, IF ANY STREET ADDRESS (NO P.O. BOX) CITY NAME OF PRINCIPAL OFFICER(S) Tom Fischer STREET ADDRESS (NO P.O. BOX) 3. Verification I have used all reasonable diligence in preparing this statement and t e st of knowledge the information contained herein is true and complete. I certify under penalty of perjury under the laws of the State TREASURER 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 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Tom Fischer for City Council 2022 • An committees must list the tinanclai Institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE Pinnacle Bank 1(408)848-7210 ADDRESS CITY 7597 Monterey Street Gilroy 4. Type of Committee Complete the applicable sections. BANK ACCOUNT NUMBER STATE ZIP CODE CA 95020 CALIFORNIA •- ' Page 2 I.D. NUMBER • 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 Tom Fischer City Council Member 2022 • 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) PARTY ® Nonpartisan ❑ Nonpartisan CHECK ONE SUPPORT OPPOSE SUPPORT OPPOSE El H FPPC Form 410 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Tom Fischer for City Council 2022 4. Type of Committee (Continued) General• • 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 NAME OF SPONSOR ki9:\f11/J11-11M j.9 List additional sponsors on an attachment. I�Na\�U7.�i773i Small Contributor Committee Date qualified CITY (INDUSTRY GROUP OR AFFILIATION OF SPONSOR STATE ZIP CODE CALIFORNIA •- ' Page 3 I.D. NUMBER 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. -- 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 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov