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Statement of Organ ization STATF.~ENTOF ORGANiZATiON <br />RecipientCommittee Type or print in Ink <br /> <br />Statement Type [] Initial [] Amendment rmination - See Part 5 - <br /> Notyet qualified [] or List I.D. number: / Lief I.D. number: <br /> <br /> / I I I I / <br /> Date qualified as committee Date qualified as committee Date of Termination <br /> (If applicable) <br /> <br />1. Committee Information 2. Treasurer <br /> NAME OF COMMITTEE NAME.-~REASUI~ER( <br /> <br /> STREET ADDRESS ( ClT)(*} .i .~ STATE A .ZIP CODE <br /> <br /> MAILING ADDRESS (IF DIFFEREN~ <br /> <br /> CI~ STATE ZIP CODE AR~ COD~PHONE <br /> OPTIONAL: F~ / E-MAIL <br /> <br /> NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE <br /> COUN~ OF DOMICILE ~ COUN~ WHERE COMMI~EE IS ACTIVE IF DIFFERENT <br /> <br /> CI~ STATE Z~P CODE AR~ CODE/PHONE <br /> A~ach additional information on appropriately labeled ~ntinuation sheets. <br /> <br />3. Verification <br /> I have used all reasonable diligence in preparing this statement and to the best of my knowledg~e ~f~rma~ion contained herein is true and complete. I certify under penalty of <br /> perjury under the laws of the State of California that the foregoing is true and correct. / ] ,~//~ ~ ~/t <br /> <br /> Executedon // ~' O~ By ~.,A,~ <br /> 11- 3:x.-oo , ,/\ <br /> <br /> Executed on ''-'' '~ By ',~ ~' 'G~A'UREOFTREASURERORASS,STANTTREASURER <br /> ~ SIG~URE O~ CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT <br /> Executed on ~ By ~ ~'~ <br /> DATE f SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT <br /> Executed on By <br /> DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE M~SURE PROPONENT <br /> <br /> FPPC Form 410 (8~99) <br /> For Technical Assistance; 916/322-5660 <br /> <br /> <br />