HomeMy WebLinkAboutForm 410 - Samantha Sargent 2011 Initiale�A
Statement of Organ'lizatio'n
Recipient Committee
Statement Type Initial
Not
)"
ot ye qualified 0 or
Date qualified as committee
1. Committee Information
NAME OF COMMITTEE
Type or print in ink I
in the
❑ Amendment ❑ Termination – See Part 5
List I.D. number: List I.D. number:
I— --J'
Date qualified as committee
(if applicable)
STREETADDRESS (NO P.O. BOX)
CITY, STATE ZIP CODE
CITY STATE ZIP CODE AREA CODEIPHONE
FAX ( E-MAIL ADDRESS
COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
Attach additional information on appropriately labeled continuation sheets.
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 ther-� laws of the State of California that the foregoing is true ar
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Executed on ' By
DATE
Executed on 4 By
DATE
Executed on
DATE
Executed on
Ill
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FIPPC Form 410 (Apri1/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
rd -
4. Type of Committee Complete the applicable sections.
[controlled committee
C,A
STATEMENT OF ORGANIZATI(
Rv A
• 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 "non-partisan."
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION
PARTY
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
" Y-- (--, C , tkw it VA
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE I BANK ACC
ADDRESS
CITY
NUMBER
STATE ZIP CODE
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)
CZ CA ( , �-,
U
CANDIDATE( - S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
FPPC Form 410 (April/201
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/276-377