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Statement of Organization ty.~ or ~ i~ I~k STATEMENT OF ORGANIZATION <br />Recipient Committee <br /> <br />Statement Type [] Initial ~l~mendment [] Termination - See Part $ For Official U~e Only <br /> Not y~t qualified [] or List I.D, number: List I.D. number: <br /> # ~/~:~ # FEB o 1 Zooi <br /> <br /> I <br /> Date qualified as c~mmiltee Date quaIled as cornmittee DaI~ of Termination <br /> <br />1. committoo Information 2. Treasurer and Other Principal Officers <br /> <br /> ciTY STATE ZIP CODE AREAC HONE NAME OF ASSISTANT TREASURER. IF Ainl~' / <br /> <br /> MAILING ADDRESS (IF DIFFERENT) <br /> <br /> CITY STATE ZIP CODE AREA CODE/PHONE <br /> OPTIONAL: FAX / E-MAIL ADDRESS <br /> <br /> NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE <br /> COUNTY OF DOMICILE ] COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT <br /> THAN COUNTY OF DOMICILE MAILING ADDRESS <br /> <br /> CITY STATE ZIP COOE AREA CODE/PHONE <br /> AItaCh additio~al i~£orme#on on appropriately labeled continuation sheets, <br /> <br />3. Verification <br /> Ipehr~uV~%nSedderal~h? laaaOw~o~h¢;l~gtateneC~i~Palim~gth~itSlhSetaftoerem~onitn;nids f~eh~nbde~.~e~.y kno~.~thej~,~7on contained herein is trueT~d complete. I certify under penalty of i X <br /> <br /> Ex~cuted o~ Sy <br /> Executed o~ By <br /> <br /> FPPC Form 410 (Jan/01) <br /> FPflC Toll-Free Help#ne: 866/ASK-FPPC <br /> <br /> <br />