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o�°9ta�@Rl@Pl� �f �6°g�Pll�c��l�il STATEMENT OF ORGANIZATION <br /> ���,����r�� �ommittee � � .- � � ' <br /> . - <br /> INSTRUCTIONS ON REVERSE <br /> Page 3 <br /> C041MITTEE NAME I.D.NUMBER <br /> 'u.-�. � i�r�r--ti„L -r-� �.i � C.�' i= - ; L ��c_ ir !�'i r .�.Cc' 'i�t%�_li.-c��f [ ; r �,� C i:��:,:C � � � .�, .`` "1 � t"j <br /> 4.Type of�o��ittee (Continued) <br /> �.. . Not formed to support or oppose specific candidates or measures in a si�gie election. Check only one box: <br /> �CITYCommittee �COUNTYCommit4ee �STATECommittee <br /> PROVIDE BRIEF DESCRIPTION OF ACTIVITY <br /> �• • -• • - List additional sponsors on an aitachment. <br /> NAtflE OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR <br /> STREET ADDRESS N0.AND STREET CITY STATE ZIP CODE <br /> . . • . <br /> �—J—_/ Check box and provide the date this committee qualified as a small contributor committee. If the committee qualified as a small <br /> Date qualified contributor committee on January 1,2001,enter 1/1/01. <br /> �J.T��•��e�afi�r� �equirements Bysigningtheverification,thetreasurer,assislanttreasurerandlorcandidate,officeholder,orproponentcertifythatallofthefollowingconditionshavebeenmet: <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 obiigations; <br /> > This committee has no surplus funds; and <br /> � This committee has filed all campaign statements required by the Political Reform Act disclosing all reportabie transactions. <br /> -- There are restrictions on the disposition of surpius carnpaign 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:866/ASK-FPPC <br />