Bury 01-15-1992 State 410 - Laserfiche WebLink

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STA'I'I!IvlI,.'Nr OF t flt(IANIZA'I'II)N Statement of Organization Type or P,I.I In Ink. ~1~~~111~I Recipient Committee SEE INSIRUOIIONS ON nEVERSE Attach additional infer.ration on appropriately labeled continuation ~heets. IV Broad Based Commiitee (See definition and important information on reverse) If lhis is a brmd ba~ commit~e and wishes Io m~e contribulions Io candidales in excess of fl~e $2,5~ conuibulion limit in conneclion wilh a s~ial el~lion, ch~k lhe ~x ~low aud enler file dale on or ~fore which lira commillee qualified as a broad based commill~. (If the core.tree is not a broad based co~nittee, or does not wish to ~ke contributions in eacess of the I2,5~ limit, do not complete this section.) ~ Check box if Ihis is a broad based commiUee. Enler lhe dale on or before which Ihe commillee qualified as a broad based cmnmillee: (s~ontn, 9a~, r.ad ~./~ · ~ Sponsored Oommilloe Is flits a Slmusor~ commillee~ ~ Yes ~ No (See instructions on reverse for ~finitions and rules regarding a sponsored committee's name.) If yes, provi~ name and address of s~umr. If dm commill~ has more Ihan cue s~nmr, ~ovide uames and addresses ou appropdalely la.led allachmenl. A~SS ~ S~: ~. AND SleET CItY SIAIE ZiP C~E ¥ I Primarill/Formed Oon~nittee If primarily formed lo support or oppose specific candidates or measures, 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.. CITY OR COUNrI'y, AS APPLICABLE) VII Committee's Primary Activity Il Not Primarily Formed If not supporting or opposing specific candidates or measures, sec instructions on reverse and check ONE box Io ifldical~ ii this is a: Iq CITY Committee or I-I COUNTY Conmnllloo or I-1 STATE Conlnlllloo prtovl~ ~FJ~IPIION OE A~I NllrY I VIII Disposition of Surplus Funds You must specify whal disposilign will be ma(k of smlflus funds in Ibc event of terminalion. ~ IX Verification I have used all reasonable diligence in prcparing~fia.slalemcn! and to the best of my knowledge I~e~nformalion conlain~d herein is linc and complete. I certify under penally of perjmy undaclh¢ laws of the $1alc of Califoroiflhal~m foregoing is U'uc .,~d correcL ( / ~ ' J~A1E ' CIIY AN() SIAIE 81GNAIUflE OF CONIROLI lNG OrrlCEtlOil~R. CANI~J)AII:. OR $1 lE MEYl~UflE PII~NENI Al Execuled on%,' By · DAIE ClIY AND SlA [E SIGNATUnE OF CON1fl(XI lNG orRcEI ICXDEfl. CANDIDAIE. OR StAle MEASURE Executed on Al By I')AIE CI I¥ AND SI'AIE SIGNAILII1E OF comno~ I SN~ orrlcEl ~3t r~n. CANt~)X~E. (~ SlA~£ I,~.ASU~$ r'IIOi~N£N!