HomeMy WebLinkAboutForm 410 - AmendmentStatement of Organization
Recipient Committee
Statement Type ❑ Initial
Not yet qualified ❑ or
I I
Date qualified as committee
1. Committee Information
NAME OF COMMITTEE
1�r C— I (Ct� 4)
Type or print in ink
Amendment
List I.D. number:
#
Date qualified as committee
(if applicable)
❑ Termination — See Part 5'
List I.D. number:
_1_ I
Date of Termination
REE ADDR S (NO P.O. BOX)
CITY / STATE ZIP CODE AReEAC/ODE /PH(OJNE
CJ
(IF DIFFERENT)
OPTIONAL: FAX/ E -MAIL ADDRESS
COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENI
THAN COUNTY OF DOMICILE
Attach additional information on appropriately labeled continuation sheets.
Date Stamp
1
2. Treasurer and Other Principal Officers
NAME OF TREASURER �)
STREETA bbR ESS (NO P.O. X)
STATEMENT OF ORGANIZATION
For Official Use Only
CITY STATE ZIP CODE ( AREACODE /PHONE
%V� K'e- '�6
NAME OF ASSISTANT TREASURER, IF ANY
STREETADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREACODE /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 (0 7� BY
�N T E O T ASURER SSISTANT TREASURER
Executed on rd�2 �t���'�� By
DATE '44 _ ❑ lrnni 11111 IrMIr 111 n1A 1.1111.TF nR STATF MFASI IRF 1Rt7PnNFNT
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDID , OR STATE MEASURE PROPONENT
FPPC Form 410 (June /09)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)
l�J
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
14iA_- . r. r .L V
4. Type of Committee Complete the applicable sections.
STATEMENT OF ORGANIZATION
Page 2
13g(�11
• 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.
ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
a List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER
STATE ZIP CODE
V U V S-4 1i 1 t( K (. _f4_
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)
CHECK ONE
)RT OPPOSE
FPPC Form 410 (June /09)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772)
Statement of Organization
Recipient Committee
Statement Type ❑ Initial
Not yet qualified ❑ or
Date qualified as committee
1. Committee Information
3.
NAME OF COMMITTEE
STATEMENT OF ORGANIZATION
Type or print in ink
Date Stamp
RECtEIVED ANU FILE
Amendment ❑Termination —See Part the f the St to secretary l ro a Si
List 1. D. number: List I.D. number:
# 1 �-_ # NOV 01 2012
s L�� t —� EBRA BOWEN
Date qualified as committee Date of Termination ecretary of Stag
(If applicable)
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
r, l '' '7 619- 1�1Z Z o 4�o F - GZ /- �
MAILING ADDRESS ADDRESS (IF DIFFERENT)
OPTIONAL: FAX/ E -MAIL ADDRESS
COUNTY OF DOMICILE ( COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENI
THAN COUNTY OF DOMICILE
Attach additional information on appropriately labeled continuation sheets.
2. Treasurer and Other Principal Officers
NAME OF TREASURER
STRE� ESS (NO P.O. OX) 'S6 9� y o
CITY STATE ZIP CODE AREACODE /PHONE
61 (4- U -7 rte' — X jZ-c.0
NAME OF ASSISTANT TREASURER, 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)
CITY STATE ZIP CODE AREA CODE /PHONE
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.
perjury under the /laws of the State of California that the foregoing is true ar
l '
Executed on 0 41/
By
DATE
Executed on 2 ��O/ 2
DATE
Executed on
Executed on
DATE
By
I certify under penalty of
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (June /09)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
4. Type of Committee Complete the applicable sections.
STATEMENT OF ORGANIZATION
Page 2
• 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.
ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPONENT
(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 / AREACODE /PHONE BANKACCOUNTNUMBER
4 od-Us- U V -7 Z 2 S- o / o 3 j3�- --/7- 7 722- 6
ADDRESS CITY STATE ZIP CODE
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)
CHECK ONE
FPPC Form 410 (June /09)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)