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Statement of Organization J, . ! c " /(I : Date Stamp
CALIFORNIA 41 Q
Recipient Commi~ee FORM
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Statement Type [S(jnitial 0 Amendment D •ermma11on - S"tte ·P.i'I'U5 C::ft'»"f\ For Official Use Only
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Date qualified as committee Date of termination
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CAILMELO
CITY
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STATE ZIP CODE AREA CODI:/PHONE--
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NAME OF ASSISTANT TREASURER, IF ANY
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MAltiNG ADDRESS (IF DIFFERENT)
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COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(S)
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 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
CALIFORNIA
FORM
41 0
INSTRUCTIONS ON REVERSE
Page
COMMITTEE NAME 1.0. NUMBER
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Controfled Committee
• List the name of each controlling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled, also Jist 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, Jist 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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No(3/ Partisan (list political party below)
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Primarily Formed Committee 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 ONE
··-~·· -··-
SUPPORT OPPOSE
JUN 12 2018
1. Candidate Information: Received by City Clerk
NAME OF CANDIDATE (last, First, Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER (optional) E-MAIL (optional)
D I accept the voluntary expenditure ceiling for the election stated above.
D I do not accept the voluntary expenditure ceiling for the election stated above.
Amendment:
0 I did not exceed the expenditure ceiling in the primary or special election held on: __]__}_ _ and I accept the voluntary expenditure ceiling for
the general or special run-off election.
(Mark if applicable)
D On __}__]_ _ , I contributed personal funds in excess of the expenditure ceiling for the election stated above.
3. Verification:
I certify under penalty of perjury under the laws of the correct.