Bury 01-15-1992 City 410 - Laserfiche WebLink

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$'I'ATI;.MENr OF OR(;ANIZ~ATION Statement of Organization Typo or Print In Ink. Recipient Committee SE[ INSIRUCIIONS ON Rg¥[flS[ Attach additional information on appropriately labeled continuation sheets. IV Broad Based Committee (See definition and important information on reverse) If Ihis is a broad based committee and wishes Io make contributions to candidates in excess of the $2,500 contribution limit in connection with a special election, check the box below and enter the date on or before which Ibe commillee qualified as a broad based committee. (If the committee is not a broad based committee, or does not wish to make contributions in excess of the $2,500 limit, do not complete this section.) [] Check box if this is a broad based committee. Enter the dale on or before which the commillee qualified as a broad based committee: (Mo.tn, V Sponsored Commillee Is this a sponsored com~niitee? I_-] Yes [] No (See instructions on reverse for definitions and rules regarding a sponsored committee's name.) If yes, provide name and address of sponsor. If the committee has mom than one sponsor, p[ovide names and addlesses on appropriately labeled attachment. AODR[SSO~c SI~ONSOR: NO AND SIR[II ClIY SIAl[ ZIPCOO[ V I Primarily Formed Committee If primarily formed lo support or oppose specific candidates or measmes, list specific candidates or measures below: CANDIDATE'S OFFICE SOUGHT OR HELD OR MEASURE'S JURISDICTION CHECK ONE CANDIDATE'S NAME OR MEASURE'S FULL TITLE (INCLUDE BALLOT NO. OR LET[ER) (INCLUDE DISTRICT NO., CID' OR COUNTY. AS APPLICABLE) VII Committee's Primary Activity i! Not Primarily Formed If not support,nc or opposing specific candidates or measures, see instructions on reverse and check · q ONE box to indicate if this is a: [] CITY Committee or [3 COUNTY Committee or [] STATE Cornmltloo PROVIDE ~F/~IPIlON 0{: AC l IVI IY VIII Disposition of Surplus Funds You must specify what dispositign will be made of surplus funds in the event of termination. i IX Verification I have used all reasonable diligence in preparing~llj~statement and lo the best of my knowledge t~be.j, nformation contained herein is true and complete. I certify under penalty of perjury unde~be laws of the Slate of Califor~ thatJ~e foregoing is tru~ ~d CDr[ecL ( I ~-~ Execuled on~ t~}, 11~ ~ ~ Al ~~,1~ ~'~(~il, By ('/'~~^lE on SIAl[ .tASUnE enOr~N[Nl ( ~ DAIE CIIY AND SlAtE ~F CONIROLLING Ol:l' ICE t IO{ D~ R. CANOIJ) . Executed on".-. ' Al By DAlE CI IY AND SIAl[ SIGNAIURE OF CON 1 ROI tING O[ Ir ICEI IC~ DER. CANDIDA 1 E. Off SIAl[ MEASUr~ PltO~'C)NE NI ~ Execuled on Al By I]A 1 E C I I Y ANI) S