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STA'I*EMENT OF ORGANIZATION Statement of Organization Type or Print In Ink. ~ Recipient Committee SEE INSIRUCIIONS ON RgVERS[ Attach _additional information on appropriately labeled continuation sheets. NAME OF COMMITTEE: Citizens to Re-elect Georgi La Berge IV Broad Based Committee (See definition and important information on reverse) If this is a broad based committee and wishes to make contributions to candidates in excess of die $2,500 conlxibulion limit in connection with a special election, check the box below and enter die date on or before which the committee qualified as a broad based commiltee. (if the committee is not a broad based co...ittee, or does not wish to make contributions in excess of the $2,500 limit, do not complete this section.) [3 Check box if this is a broad based committee. Enter the date on or before which the rommiltee qualified as a broad based committee: (Month, Day, Year) ¥ Sponsored Commlilee is this a sponsored committee? [3 Yes [3 No (See instructions on reverse for definitions and rules regarding a sponsored comtnittee's ns.re.) If yes, p~ovide name and address of sponsor. If the committee has more than one sponsor, provide names and addresses on appropriately labeled atlachment. NAME O~c S.aONSOR ADORESS OF SPONSOR: NO AND SIREET CIIY SLATE ZIP COOE V I Primarily Formed Committee If primarily formed to supper or oppose specific candidates or ,neasutes, list specific candidates or measures below: CANDIDAIE'S OFFICE SOUGHT OR HELD OR MEASURE'S JURISDICTION CHECK ONE CANDIDATE'S NAME OR MEASURE'S FULL TITLE (INCLUDE BALLOT NO. OR LE'rfER) (INCLU[~ DISTRICT NO.. CITY OR COUNTY, AS APPLICABLE) VII Committee's Primar~ Activity il Not Primarily Formed If not supporting or opposing specific candidates or measures, see instructions on reverse and check ONE box to indicate if this is a: [] CITY Committee or [3 COUHTY Committee or [3 STATE Committee P~IE)~ B,REF [~SCFIhOT~OH OF ~TfVtTY VlllDisposition o! Surplus Funds You must specify what dispositign will be made of surplus funds in thc event of termination. IX 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.../ _/laws of the Stare of California that thc foregoing is~lrue a0d correct. J'~o '~ .47_ ~.. J /~.-/~-. ~ - By · , SIG'UAtrURE OF TREASURER )~ Executed on / At ~ ~/ ' By SlGNAIURE OF COI,~ROtUNG OITICI~!,O[D£n. C^I19DATE. On ST^'IE MEASURE Executed on At By DAlE ClIY AND SIAIE S GNATURE OF CONIROLI lNG OEFICEIIOI DER. CANDIDA1 E. OR StAlE MEASURE PfIOPONIZN I Execuled on At By DAlE CI I Y AND SIAIE SIGNAl URE OF CONIIIOI I lNG O1' FIC[I IOI DER. CANDIDAIE. OR StAlE MEASUIIE PROUONENI