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STATEMENT OF ORGANIZATION Statement of Organization TypeorPrlntlnlnk. ~ Recipient Committee SEE IN$1RU~IION$ ON REVERS[ Attach additional i~ornmtion on appropriately labeled continuation sheets. N~E ~ C~MITTEE: Citizens to Re-elect Georgi La Berge IV Broad Based Co~ittee (See deflation and i~ortant i~or~tion on reverse) If this is a b~md ba~ commitme and wishes !o m~e conuibufions Io c~didates in excess of ~e $2,5~ conuibution limit in connection with a s~ial elation, check the ~x ~low and enter ~e date on og ~fo[e which t~ commiltee qualified as a broad based commiU~. (if the com.dttee is not a broad based co~tittee, or does not wish to nmke contributions in excess of the $2,5~ li~t, ~ not co~lete this section.) k3 Check box if th~ is a broad ba~d ~ommittee. Enter the dale on or before which the ~ommiUee qualified as a broad based rommittee: (Month, Day, Year) V Sponsored Com~ltee is fids a s~nm~ commilt~? ~ Yes ~ No (See instr~tions on reverse/or ~finitions and rules regarding a sponsored co.unittee's name.) If yes, ~ovi~ name ~d ~ess of s~nm[, if ~e committ~ has more th~ one s~nmr, ~ovide nmnes and addresses on appropriately la.led almchmem. A~ ~ ~: ~ AND STREET GUY STATE ZIP C~E V I Primarily Formed Con~nittee If pfimaxily formed to supped or oppose specific candidates or ;neasmcs, list specific candidates or measures below: CANDIDA'IE'S OFFICE SOUGH[ OR HELD OR MEASURE'S JURISDICTION CHECK ONE CANDIDATE'S NAME OR MEASURE'S FULL TITLE (INCLUDE BALLOT NO. OR LETTER) (INCLUC)E DISTRICT NO., Cllh' OR COUNTY, AS APPLICABLE) VII Committee's Primary Activity il Not Primarily Formed If not suppomng or opposing specific candidates or measures, sec instrucuons on reverse and check ONE box lo indicate if this is a: [] CiTY Committee or [] COUHTY Commlltee or Fl STATE Committee Pl~OVIl~ I~IEF DE. SCnlPTIC~I C~= ACINIIY VllIDisposition of Surplus Funds You must specify what dispositio.:~ 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 [rue and complete. I cerlify under penalty of perjury under thc laws of /thc State of California that thc foregoing is~true apd correct. Execuled on /~/ / Al CITY ANO SlAIO ~/ By SIGNAIURE O[ CO~RC~t lING Ot-FIC[IIOI DER. C ,.jDATE, Ott SIAl[ MEASURE [IIOPON[NT Executed on At By DAlE ClIY AND SIAIE SIGNAl UIIE OF CONIRO[t lNG O[FICEIIOJ DER. CANDtDAI£. Oil STAIE MEASURE PftOF~ONEN I Executed on Al By DAlE CI IY AND SIAl[ SlGNAIUII[ O1: CON1ROI I lNG OI I[C[I IOI DIll. CAN{)II)A I [. OII SIAl[ M[ASUII[ r'I1OPONI HI