Fppc Form 410 - Statement Of Organization - Recipient Committee Page 2

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Statement of Organization

410

CALIFORNIA

Date Stamp

Recipient Committee

FORM

Statement Type

Initial

Amendment

Termination – See Part 5

For Official use Only

Not yet qualified

Date qualified as committee

Date of termination

I.D. Number

1. Committee Information

2. Treasurer and Other Principal Officers

(if applicable)

nAMe OF TReASuReR

nAMe OF COMMITTee

STReeT ADDReSS (nO P.O. BOx)

CITy

STATe

zIP CODe

AReA CODe/PHOne

CITy

STATe

zIP CODe

AReA CODe/PHOne

nAMe OF ASSISTAnT TReASuReR, IF Any

STReeT ADDReSS (nO P.O. BOx)

MAIlIng ADDReSS (IF DIFFeRenT)

CITy

STATe

zIP CODe

AReA CODe/PHOne

e-MAIl ADDReSS (RequIReD) / FAx (OPTIOnAl)

COunTy OF DOMICIle

JuRISDICTIOn WHeRe COMMITTee IS ACTIve

nAMe OF PRInCIPAl OFFICeR(S)

STReeT ADDReSS (nO P.O. BOx)

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

SIgnATuRe OF TReASuReR OR ASSISTAnT TReASuReR

executed on

DATe

SIgnATuRe OF COnTROllIng OFFICeHOlDeR, CAnDIDATe, OR STATe MeASuRe PROPOnenT

executed on

DATe

SIgnATuRe OF COnTROllIng OFFICeHOlDeR, CAnDIDATe, OR STATe MeASuRe PROPOnenT

executed on

DATe