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Statement of Organization <br />Recipient Committee <br />INSTRUCTIONS ON REVERSE <br />COMMITTEE NAME <br />Page 3 <br />I.� NUM6ER <br />Generat Purpose Committee 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 CFACTIVITY <br />NA <br />• List additional sponsors on an attachment. <br />NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR <br />STREET ADDRESS NO, AND STREET CITY STATE ZIP CODE AREAODDEIPMQ'AE <br />Smaff Contributor • ❑ �� <br />[:are qvi r,•, <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 />— Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511 - <br />89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5. <br />FPPC Form 410 (August/20181 <br />FPPC Advice: advice0fonc.ca.eov(866J275-377ZI <br />www.fpnc.ca.eov <br />