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Statement of Organization STATEMENT OF ORGANIZA?lON <br /> Recipient Committee , �. , ' <br /> . - <br /> � <br /> INSTRUCTIONS ON REVERSE <br /> Page 3 <br /> COMMITTEE NAME <br /> I.D.NUMBER <br /> t�:,�. �'T„�-�. rt� L,t C.C'7" i�•-r. � t. �c:_� i 1/_Y t- f-f C+� ��C��t i.-���t� i' ;y°.- C t��✓t L ,' ) � _7�� �"' 1 G�1 <br /> 4.Type of Committee (Continued) <br /> '� ' • Not formed to support or oppose specific candidates or measures in a single election. Check only one box: <br /> �CITYCommittee �COUNTYCommittee �STATECommittee <br /> PROVIDE BRIEF DESCRIPT�ON OF ACTIVITY <br /> • � �� � Listadditionaisponsorsonanattachment, <br /> NAME OF SPONSOR INDUSTRY GROUP ORAFFILIATIONOF SPONSOR <br /> STREET ADDRESS NO.AND STREET CITY STATE ZIP CODE <br /> • � • • <br /> ���J Check box and provide the date this committee qualified as a smali contributor committee. If the committee qualified as a small <br /> Datequalified contributorcommitteeonJanuary1,2001,enter1/1/01. <br /> �J.T@PillltlBtlOf1 R@C�UIC@I'Yl@17tS Bysigningtheverification,thetreasurer,assistanttreasurerand/orcandidate,officeholder,orproponentcertifythatallofthefoliowingconditionshavebeenmet: <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 <br /> Government Code Section 89519. <br /> -- Additional filing obligations will be incurred if, after 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(Jan/01) <br /> FPPC Toll-Free Helpline:866lASK-FPPC <br />