HomeMy WebLinkAboutForm 410 - Mahmoud A. Shirazi; TerminationStatement of Organization
Recipient Committee
NAME OF COMMITTEE
CITY en STATE ZIP CODE ��AREACODE/PHONE
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FULL MAILING ADDRESS (IF DIFFERENT)
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E-MAIL ADDRESS OF COMMITTEE (REQUIRED) / FAX (OPTIONAL)
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COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
Attach additional information on appropriately labeled continuation sheets.
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ITY CLERK'S OFFIC
NAME OF TREASURER
STREET ADDRESS (NO P.O. BOX) CITY
EMAIL ADDRESS OF TREASUREB(REQUIRED)
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX) CITY
EMAIL ADDRESS OF ASSISTANT TREASURER (REQUIRED)
PRINCIPAL OFF]
STREET ADDRESS (NO P.O. BOX) CITY
EMAIL ADDRESS OF PRINCIPAL OFFICER(S) (REQUIRED)
For Official Use Only
STATE ZIP CODE
AREA CODE/PHONE
STATE ZIP CODE
AREA CODE/PHONE
STATE ZIP CODE
AREA COD
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
OR STATE MEASURE PROPONENT
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
FPPC Form 410 (October/2023)
FPPC Advice: adviae func.ca.gov (866/275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME'S";��P��O I.D.
• All committees must list the financial institution where the campaign bank account is located and the person(s) authorized to obtain bank records.
NAME OF FINANCIAL INSTITUTION AND PERSON(S) AUTHORIZED TO OBTAIN BANK RECORDS
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ADDRESS OF FINANCIAL INSTITUTION
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AREA CODE/PHONE ( BANK ACCOUNT NUMBER
CITY �E ZIP COD
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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 APPLICABLE) ELECTION CHECK ONE
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Nonpartisan
Partisan
(list political party below)
Nonpartisan
Partisan
(list political party below)
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)
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410(October/2023)
FPPC Advice: advice -Qc.ca.goy (866/275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D. NUMBER
a rl rs f •7-$j �
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
Date qualified
• 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.
ZIP CODE AREA CODE/PHONE
— 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 (October/2023)
FPPC Advice: ,deice fyrc.ca..go r (866/275-3772)