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Statement of Organization STATEMENT OF ORGIWVATION <br /> Recipient Committee ' �;� ' � 1 <br /> I INSTRUCTIONS ON REVERSE <br /> Paga 3 <br /> COMMITTEE NAME I.D.NUMBER <br /> 4.Type of Committee (c«,vo�ea) <br /> •� • Not tamed to support or oppose specific candidates or measures in a single election. Check only one box: <br /> �CITYCommittee �COUNTYCommittee �STAiECommittee <br /> PROVIDE BRIEF DESCRIPTION OF ACTIVITV <br /> .. . Listadditionalsponsorsonanallachment. <br /> NAME OF SPONSOR INDUSTRY GROUP OR AFFILIRTION OF SPONSOR <br /> • <br /> STREET ADDRESS NO.AND STREET CfiY STATE ZIP CODE <br /> ' ' � �� Chedc box and provide Me date ihis committee qualified as a small contribula cammittee. If Me commi�ee qualified as a small <br /> Date qualified contributor commitlee on January 1,2001,enter 1/1I01. <br /> 5.T@�IT11�18tIO�IR@QUIf@R1CntS Bysigningiheverification,Metreasurer,assistanttreasurerandlorcarMidate,olficeFwlder,wproponentcertifythatailotthetollowingcadNOnshavebeenmet <br /> • This committee has ceased to receive conVibutions 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 intention 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 Politiral Reform Act disclosing all reportable transactions. <br /> -- There are restrictions on the disposition of surplus campaign funds held by elected officers who are leaving office and by defeated candidates. Refer to <br /> Govemment Code Section 89519. <br /> -- Additional filing obligations will be incurred if, atter terminating, the committee receives or spends any funds, or receives the forgiveness of a loan, <br /> repayments of loans made to others, or any other receipts. <br /> FPPC Form 410(JanI07) <br /> FPPC Toll-Free Helpline:8661ASK-FPPC <br />