HomeMy WebLinkAboutForm 410 - Samantha Sargent for City Council 2011 TerminationStatement ofOrganization
Recipient Committee
Statement `hype El initial
Not yet qualified or
Cate qualified as committee
Amendment
List I.D. number:
Date qualified as committee
(If applicable)
Termination — See Part 5
uis I.D. number:
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STREET ADDRESS ._
CITY STAT E ZIP CODE
AREA
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
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Date of Termination
StampDate
IFICEWED
the office of the Secreta,,y
of si
r
DEC 3 0 2013
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CGDE
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODEIPHONE
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 lavers of the State of is that the foregoing is true and correct
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Executed on - t By
DATE Slfs%3 E OF ARER OR ASSISTANT TREA 'RER
Executed on By
GATE SIGNATURE OF CONTROLLIN FFICEHO DER, CANDIDATE, 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, ER, CANDIDATE, OR STATE MEASURE PROPONENT
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FPPC Form www.fppc.c,aJ.go
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
rem
* All committees must list the financial institution where the campaign bank account is located
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NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE
kc- OF 14 2 -
ADDRESS CITY
F-00
4. Type of Committee Complete the applicable sections.
BANK ACCOUNT NUMBER
STATE ZIP CODE
• 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."
• 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 CAN D1 DATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
FO
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A Primarily formed to support or oppose specific candidates or measures in a single election. List below:
7
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
Suppo T
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FPPC Form 410 (Dec/2012)
FPPC Advice: advice@fppc.ca.gov (3661275-3772)
www.fppc.ca.gov