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� <br /> Statement of Organization � • - � � , <br /> Recipient Committee • � <br /> INSTRUCTIONS ON REVERSE <br /> Page 3 <br /> COMMITTEE NAME I.D.NUMBER <br /> �� ' T re..�. 'TG �� C T t�v� � L �1., ', �r -�i.� i2 ec.^�U;C <r� � ) 'T % C v v Yi C i ) <br /> ����t,������ t�t�¢�.- _ . . _ <br /> �� • � Not formed to support or oppose specific candidates or measures in a single election. Check only one box: <br /> ❑ CITY Committee ❑ COUNTY Committee❑ STATE Committee <br /> PROVIDE BRIEF DESCRIPTION OF ACTIVITY <br /> .. • List additional sponsors on an attachment. <br /> NAME OP SPONSOR IRDUSTRY GftOUP OR AFFILIATION OF SPONSOR <br /> STREETADDRESS NO.ANDSTREET C�TY STATE ZIPCODE <br /> r � i � � ❑ <br /> � � <br /> Date qualified <br /> �1.�#:���tt�t"��c�E1�l`�f�iE'� B�sign)rigtE�ev��e��ytfie��surer.assis�an�#r��urerand�orca�c�'i€3�te,�tu>lcfer,orprQ�rctner�i�rb`fythataEt�t#�e�c�figwingtondi�itt�s��en-rnEt: . . <br /> • This committee has ceased to receive contributions 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 Political 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 Government <br /> Code Section 89519. <br /> -- Leftover funds of ballot measure committees may be used for political,legislative or governmental purposes under Government Code Sections 89511-89518,and are <br /> subject to Elections Code Section 18680 and FPPC Regulation 18521.5. <br /> FPPC Form 410(Dec/2012) <br /> FPPC Advice:advice@fppc.ca.gov(866/275-3772) <br /> www.fppc.ca.gov <br />