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Home My WebLink AboutDon Gage - Form 410 - AmendmentSfatement of Organization STATEMENT OF ORGANIZATION Recipient Committee Type or print in ink Date Stamp 1 MOfffificial Statement Type ❑ Initial ® Amendment ❑ Termination — See Part 50�nly Not yet qualified ❑ or List I.D. number: List I.D. number: # 1346217 # —0 y /A OD jai —J —J Date qualified as committee Date qualified as committee Date of Termination (If applicable) 1. Committee Information 2. Treasurer and Other Principal Officers NAME OF COMMITTEE NAME OF TREASURER Don Gage for Mayor 2012 Sara Humphrey -Nino STREETADDRESS (NO P.O. BOX) 7937 Hanna Street STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE /PHONE 771 4th Street Gilroy CA 95020 -4412 (408) 847 -4330 CITY STATE ZIP CODE AREA CODE /PHONE NAME OF ASSISTANT TREASURER, IF ANY Gilroy CA 95020 (408) 842 -2968 STREETADDRESS (NO P.O. BOX) MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE AREACODE /PHONE OPTIONAL: FAX/ E- MAILADDRESS dongage @verizon.net NAME OF PRINCIPAL OFFICER(S) COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE STREETADDRESS (NO P.O. BOX) Santa Clara CITY STATE ZIP CODE AREA CODE /PHONE Attach additional information on appropriately labeled continuation sheets. 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 DATE Executed on 0 q -011 -- OLo, a . DATE Executed on DATE Executed on DATE By By 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 (8661275 -3772) Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Don Gage for Mayor 2012 STATEMENT OF ORGANIZATION Page 2 1346217 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 "non- partisan." • If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. NAME OF CANDIDATE /OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY Don Gage Gilroy Mayor 2012 ® Non- Partisan ❑ Non - Partisan • 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 Santa Barbara Bank & Trust 408 - 846 -1256 0103877841 ADDRESS CITY STATE ZIP CODE 8000 Santa Teresa Blvd Gilroy CA 95020 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 SUPPORT OPPOSE FPPC Form 410 (June/09) FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772) Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Don Gage for Mayor 2012 4. Type of Committee (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 NAME OF SPONSOR List additional sponsors on an attachment. ❑ II Date qualified CITY DUSTRY GROUP OR AFFILIATION OF SPONSOR STATE STATEMENT OF ORGANIZATION Page 3 1346217 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 (June /09) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772) Statement of Organization Recipient Committee Statement Type ❑ Initial Not yet qualified ❑ or Date qualified as committee 1. Committee Information NAME OF COMMITTEE Don Gage for Mayor 2012 STREETADDRESS (NO P.O. BOX) Type or print in ink ® Amendment List I.D. number: # 1346217 DYl40°6.JA40 Q Date qualified as committee (If applicable) STATEMENT OF ORGANIZATION ❑ Termination — See Part 5 List I.D. number: 771 4th Street CITY STATE ZIP CODE AREA CODE /PHONE Gilroy CA 95020 (408) 842 -2968 MAILING ADDRESS (IF DIFFERENT) OPTIONAL: FAX/ E- MAILADDRESS dongage @verizon.net COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE Santa Clara Attach additional information on appropriately labeled continue1on sheets. Date of Termination Date Stamp ILECEIVED AND FI the Offithe of the State of Cal forni APR 0 4 2012 DEBRA BOWE Secretary of Sta 2. Treasurer and Other Principal Officers NAME OF TREASURER Sara Humphrey -Nino STREETADDRESS (NO P.O. BOX) 7937 Hanna Street CITY STATE ZIP CODE AREA CODE /PHONE Gilroy CA 95020 -4412 (408) 847 -4330 NAME OF ASSISTANT TREASURER, IF ANY STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREACODE/PHONE NAME OF PRINCIPAL OFFICER(S) STREETADDRESS (NO P.O. BOX) 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 DATE Executed on DATE Executed on DATE Executed on DATE By By 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 Don Gage for Mayor 2012 4. Type of Committee Complete the applicable sections. STATEMENT OF ORGANIZATION Page 2 1346217 • 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 Don Gage Gilroy Mayor 2012 ® Non - Partisan BANK ACCOUNT NUMBER Santa Barbara Bank & Trust ❑ Non - Partisan • 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 Santa Barbara Bank & Trust 408 - 846 -1256 0103877841 ADDRESS CITY STATE ZIP CODE 8000 Santa Teresa Blvd Gilroy CA 95020 MUMIM 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 OPPOSE FPPC Form 410 (June /09) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772) Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Don Gage for Mayor 2012 4. Type of Committee (Continued) Not formed to support or oppose specific candidates or measures in a single election. Check only one box: E] CITY Committee ❑ COUNTY Committee ❑ STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY List additional sponsors on an attachment. NAME OF SPONSOR STREETADDRESS NO. AND STREET Date qualified CITY INDUSTRY GROUP OR AFFILIATION OF SPONSOR ZIP CODE STATEMENT OF ORGANIZATION Page 3 1346217 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 (June /09) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)