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.~tatement of Organization STATEMENT OF ORGANIZATION <br />Recipient Committee Type or pdnt in ink DateStamp <br /> <br />Statement Type [] Initial mendment [] Termination - See Part 5 ' , · - ForOfficlal UseOnly <br /> / L~t I.D. number. List I.D. number: <br /> Not yet qualified <br /> or <br /> <br /> Date qualified as committee Date qualified aS committee Date of Termination <br /> (If applicable) <br /> <br />1. Committee Information 2. Treasurer and Other Principal Officers <br /> NAME OF COMMITTEE NAME OE..TREASURER <br /> <br /> CIT'~.~ -- -- .-' BATE ZIP CODE AREA CODE/PHONE <br /> <br /> ClTY/~ ~ __ *, STATE ZIP CODE <br /> <br /> ;O~Y OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT J~/~ M'~'"~ <br /> THAN COUNTY OF DOMICILE <br /> <br /> CI~ . ~A~ ZIP CODE AREA COD~PHONE <br /> Aflach add~onal info riately labeled ~ntinuaUon sheets. ... ~ ~ 2 <br />3. Verification <br /> I have used all reasonable diligence in preparing this statement and to the best of my knowledge the infor~}.ion contained herein is true and complete. I ce~i~ under penalty of <br /> oeriu~ un~e~the laws of the State of California that ~e fore~ip9 is true and correct. ~ m~ <br /> <br /> Ex~uted on ¢-~ 'zA~E ~ <br /> DATE <br /> SIG~URE OF~G OFFICEHOLDER, CANDID~E, OR STATE M~URE PROPONENT <br /> Exe~ed <br /> DATE SlGN~UBE O~ CONTROLLING OFFICEHOLDER, CANDID~E, OR ~ATE ME~URE PROPONENT <br /> Executed on <br /> DATE Sl6~URE OF OO~RO~IN60FFICEHOLDE~ CANDID~E, OR STYE M~URE PROPONENT <br /> <br /> FPPC Form 410 (Jan/01) <br /> FPPC Trill. Free Hnlnlln~..' REI~IA~K-FPPC <br /> <br /> <br />