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Daniel Harney - Form 410 AmendmentStatement of Organization Recipient Committee Statement Type ❑ Initial Q Not yet qualified or 0 Date qualified as committee 1. Committee Information NAME OF COMMITTEE KAmendment Date qualified as committee (If aminding to provide this date) I.D. Number 4r-,v--wrr -` �vCv C" t-3 t x l✓ tid i ❑ Termination – See Part 5 - - /— ✓— Date of termination �[EM� 0d�r NOV 21 2017 Ip 2. Treasurer and Other Principal Officers FF y L1 L STREET ADDRESS (NO P.O. BOX) � CITY STATE ZIP CODE AREA CODE /PHONE q 1 Lrx-ok-\ C-Ac rt m MAILING ADDRESS (IF DIFFERENT) E- AIL ADDRESS ()l FAX (OPTIONAL) COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE SA'Zorr,;- G IR-PC Q c L (Lo t j Attach additional information on appropriately labeler continuation sheets. NAME OF TREASURER STREET ADDRESS (NO P.O. BOX) For Official Use Only CITY STATE ZIP CODE AREA CODE /PHONE G i L� (L-e) Ll C/Ar NAME OF ASSISTANT TREASURER, IF ANY S/nLET ADD SS(N0 P.O. BOX) CITY STATE ZIP CODE AREA CODE /PHONE G-- L v-0 C kit- 1:2: o.-k t3 10" le $ 41-T V1 g AME OF PRINCIPAL OFFI R(S) STREET ADDRESS (NO P.O. BOX) CITY STATE ZIPCODE AREA CODE /PHONE Verification 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 Cali'ornia that the foregoing is true and correct. Executed on %.1 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 'e'y � (4> 1-) 1--)C4 i- ZO-I FPIP • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER P I" NJ acct- L (►-Ju-- +o R ?, z 7-01 w. 13 -L, 7, AUUKk SS CITY STATE ZIP CODE 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 "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 PROPONI_NT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY • 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 BALLCT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) SUPPORT Nonpartisan ❑ Nonpartisan • 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 BALLCT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (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 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 COMMITTEE NAME I.D. NUMBER 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 i] COUNTY Committee ❑ STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY TC'g- c= Ta i.c.�c.f �� �. 4w -tj C'`^ -k < % -p-em, C.',�,t • • List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREETADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE /PHONE Small Contributor Date qualified 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 (May /2017) FPPC Advice: advice@fppc.ca.gov (866/275 -3772) www.fppc.ca.gov Statement of Organization Date Stamp Ffecipient Committee - Statement Type RECEIVED AND ��IL�� ❑ Initial Ql Amendment ❑ Termination — See Palf #ie o Ice of the Secretary of State For Official Use Only • Not yet qualified o the State of California or • Date qualified as committee NOV 2 7 2017 Date qualified as committee Date of termination (If amending to provide this date) 1. Committee Information i.D. Number (i qp licable) 2. Treasurer and Other Principal Officers I � , NAME OF COMMITTEE 14r,.,v —wE "A %� C 11,3 t t t., 7.01 I STREET ADDRESS (NO P.O. BOX) MAILING ADDRESS (IF DIFFERENT) COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE Attach additional information on appropriately labeled continuation sheets. NAME OF TREASURER 30A-,J Lx,,A) s STREET ADDRESS (NO P.O. BOX) NAME OF ASSISTANT TREASURER, IF ANY 65-1 l r0 ! R(S) C AME OF PRINCIPAL OFFI A ':J l ;' U STREET ADDRESS (NO P.O. BOX) 2O CITY STATE ZIP CODE AREA CODE /PHONE 1 L (Zed � �,4- q �a z U � ! 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 u penalty of perjury under the laws of the 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 • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER `P n ADDRESS CITY STATE ZIP CODE 4. Type of Committee SCom ettiie app�ica6] milli Controlled Committee • 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. NAM E OF CAN DIDATE /OFFICEHOLDER /STATE M EASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY N, x �—v R-P, a � C, La-,-)'A, QA T- -'� �c v �Cri 2- c� t E Nonpartisan SUPPORT ❑ Nonpartisan Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S) NAME OR MEASURE(S) FULLTITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (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 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 CW 4. Type of Committee (Continued) Committee — General Purpose 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 t_ "(a e��. c� r + FJ�`_(, i-�0.Rt.� C ` \ �i t Lp__e)-"A\, r k • • List additional sponsors on an attachment. NAME OF SPONSOR STREET ADDRESS NO. AND STREET Smal! Contributor Committee ■ D CITY INDUSTRY GROUP OR AFFILIATION OF SPONSOR STATE ZIP CODE AREA CODE /PHONE 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 maybe 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 (8661275 -3772) www.fppc.ca.gov