HomeMy WebLinkAboutForm 410- Greg Brockbank for City Council 2013statement of Organization
Type or print In Ink
Recipient Committee
Statement Type Initial Amendment
Not yet qua lifiecl or Ust I.D. number:
#
101i
Date qualified as committee Date qualified as committee
(if appicab*)
Date Stamp
0 Termination — See Part 5
List I.D. number:
Date of Termination
1. Committee Information
NAME OF COMMITTEE
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STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
C..
MAILING ADDRESS (IF DIFFERENT)
OPTIONAL: FAX/ E-MAILADDRESS
/
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
Attach additional Infonnation on appropriately labeled conUnuation sheets.
2. Treasurer and Other Principal Officers
NAME OF TREASURER
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STREETADDRESS (NO P.O. BOX)
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CITY STATE ZIP CODE AREA CODEJPHON
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NAME OF ASSISTANT TREASURER, IF ANY
STREETADDRESS (NO P.O. BOX)
c11; STATE ZIP CODE AREA CODEJPHOW�
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.
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Executed on By $Xaxk�
UAI t: SIGNATURE OF TREASURER OR ASSISTANT TREASURER
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
Executed on By -"M T
DATE SIG TURF OF CONTROLLING OFFICEHOLDER, CAN 53ATE, OR STATE WMURE PRO NEN
FPPC Form 410 (April/2011)
FPPC Toll -Free Helpllne: 8661ASK-FPPC (8661275.3772)
Statement of Organization
Recipient Commiftee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
4. Type of Committee Complete the applicable sections.,
OF N A ft,i
• 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.
n
* 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
e List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL'INSTITUTION AREACODE/PHONE BANKACCOUNTNUMBER
tA P�(tTN
ADDRESS CITY STATE ZIP CODE
ily � � (��woea �ighw� �, Qc�o�� � �4Q03
Primarily Formed Committe
11 RV1111111
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I
WN
FPPC Form 410 (April/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (8661276-3772)
Non -Partisan
'Non -Partisan
e List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL'INSTITUTION AREACODE/PHONE BANKACCOUNTNUMBER
tA P�(tTN
ADDRESS CITY STATE ZIP CODE
ily � � (��woea �ighw� �, Qc�o�� � �4Q03
Primarily Formed Committe
11 RV1111111
•
I
WN
FPPC Form 410 (April/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (8661276-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
4. Type of CommilfteP (continued)
oil Not formed to support or oppose specific candidates or measures In a single election. Check only one box:
0 CITY Committee COUNTY Committee 0 STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
rs on an attachment.
'Sponsored Committee List additional sponsors
NAME OF SPONSOR (INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREETADDRESS NO, AND STREET CITY STATE ZIP CODE
Small Contributor Committee
Date qualified
STATEMENT OF ORGANIZATION
I CALIFORNIA A d 1%
5. Termination Requirements By signing the verification, the treasurer,' assistant treasurer and/or candidate, officeholder, or proponent certify that all of the foil 'ng conditions have been met:
0 This committee has ceased to receive contributions and make expenditures;
0 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 officersw'ho are leaving office and by defeated candidates. Defer 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 April 20
FPPC Toll -Free Helpline-, 866/ASK-FPPC (866/275-3772)