HomeMy WebLinkAboutAFTAB Form 410 Terminate" -.
D Amendment
Statement of Organization
Recipient Committee
Statement Typel .-0-ln-it-ia_l ______ __,l.------------,[iz(.---...---------,l'tf:=1c=tc""· -.,c .... ,+-t -.,.1..,h
Termination REC EIVED
0 Not yet qualified
or
0 Date qualification threshold met I Date qualification threshold met
I.D. Number
(if applicable/ i.oo\
NAME OF COMMITTEE
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STREET ADDRESS (NO P.O. BO X)
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CITY STATE ZIP CODE AREA CODE/PHONE
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FULL MAILING ADDRESS (IF DIFFERENT)
E·MAIL ADDRESS (REQUIRED)/ FAX (OPTIONAL)
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COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
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Attach additional information on appropriately labeled continuation sheets.
Date of termination
NAME OF TREASURER
D At-\. '-{AL I(,~ --n-1 ~I
STREET ADDRESS (NO P.O . BOX)
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CITY . STATE
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NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY STATE
CALIFORNIA 41 0
FORM
. For Official Use Only
ZIP CODE AREA CODE/PHONE
C/5670
ZIP CODE AREA CODE/PHONE
ZIP CODE AREA CODE/PHONE
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 nder he laws of the State Californi hat t;t,e foregoing is true and correct. , I v' I V t j:::;71?" ~
Executed on ~ By --=---4---·-· --'~..:....--=:...:..." _________________________ _
DATE
Executed on 1t2t f 2-7)-i, By
DATE
Executed on
DATE
By
Executed on By
DATE
SIGNATURE OF TREASURER OR ASSISTANT TREASURER
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING CFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (August/2018)
FPPC Advice: adv ice@fppc.ca.gov (866/275-3772)
www.fppc.ca .gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
CALIFORNIA 41 Q
FORM
General Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
D CITY Committee D COUNTY Committee D STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE
Small Contributor Committee D--1---1--
Date qualified
5. Termination Requirements By signing the verification, the treasurer, assistant trea~urer and/or candidate, officeholder, or ponent 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 {August/2018}
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov