HomeMy WebLinkAboutForm 410 - Mahmoud A. ShiraziStatement of Organization
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Committee1. I.D. Number
2. Treasurer and Other PrincipalOfficers
(if applicable)
NAME OF COMMITTEE
NAME OF TREASURER
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CITY STATE ZIP CODE AREA CODE/PHONE
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OF ASSISTANT TREASURER, IF ANY
FULL MAILING ADDRESS (IF DIFFERENT) \
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STREET ADDRESS (NO P.O. BOX)
E- MAIL ADDRESSIREQUIRED)/FAX (OPTIONAL)
CITY
STATE
ZIP CODE AREA CODE/PHONE
COUNTY OF DOMICILE
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JURISDICTION WHERE COMMITTEE IS ACTIVE
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NAME OF PRINCIPAL OFFICER(S)
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additional information on appropriately labeled continuation sheets.
CITY
STATE
F
ZIP CODE AREA CODE/PHONE
, .
Verification3.
1 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 and r the laws of the State
MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410(August/2018)
FPPC Advice: advice Pfppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 2
COMMITI EE NAME
,'� I.D. NUMBER
All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
ADDRESS_ CITY TATE ZIP CODE
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• 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 "nonpartisan" Stating "No party preference" is acceptable
• 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 YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLEI ELECTION
Nonpartisan
Partisan
(list political party below)
Nonpartisan
Partisan
(list political party below)
Primarily Formed Commiffee 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
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONF
SUPPORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization CALIFORNIA
Recipient Committee FORM 410
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D. NUMBER
441�00�:of
General Purpose Committee w 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
+• 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
❑ /
Date qualified
iRequireMent$ By signing the verification, the treasurer, assistant treasurer and/or candidate, officehol I der, or ponentcertifV 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