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a <br /> Statement of Organization � • - � ,� <br /> Recipient Committee � <br /> i ' <br /> INSTRUCTIONS ON REVERSE <br /> Page 3 <br /> COMMITTEE NAME I.D.NUMBER <br /> 5�.��� S�r � � c,.�a�� C:.� C au - `�-a�� <br /> • • • �� - • Not formed to support or appose specific candidates or measures in a single election. Check only one box: <br /> ❑ CITY Committee ❑ COUNTY Committee❑ STATE Committee <br /> � PROVIDE BRIEF DESCRIPTION OF ACTIVITY . <br /> •. • •• • •-. List additional sponsors on an attachment. <br /> NAME OF SPONSOR INDUSTRY GROUP OR AFFIl1ATION OF SPONSOR <br /> STREETADDRESS NO.ANDSTREET CITV STATE ZIPCODE <br /> r � � ♦ � <br /> �� <br /> Date qualified � <br /> • This committee has ceased to receive contributions and make expenditures; <br /> • This committee does not anticipate receiving contributions or making expenditures in the future; <br /> • This committee has eliminated or has no intenfion or ability to discharge all debts, loans received,and other obligations; <br /> • This committee has no surplus funds;and <br /> • This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transacfions. <br /> -- There are restrictions on the disposifion af surplus campaign funds held by elected officers who are leaving office and by defeated candidates. Refer to Government <br /> Code Section 89519. <br /> -- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511-89518,and are <br /> subject to Elections Code 5ecfion 18680 and FPPC Regulation 18521.5. <br /> FPPC Form 410(DecJ2012) <br /> FPPC Advice:advice@fppc.ca.gov(866/275-3772) <br /> www.fppc.ca.gov <br />