Laserfiche WebLink
Statement of Organization STATEMENT OF ORGANIZATION <br />Recipient Committee File original and one copy with: <br /> Secretary of State <br /> Political Reform Division <br />Amendment P.O. Box 1467 For Official Use Only <br />[] Check box if an Amendment Sacramento, CA 95812-1467 <br /> and enler I.D. number: County and City Committees file a copy ~ <br /> Local filing officer who will receive the original <br /># disclosure statemenls. <br />INSTRUCTIONS ON REVERSE Type or print in ink <br /> <br />1. Committee Information 2. Treasurer and Other Principal Officers <br /> <br /> Date qualified as committee 6 ! / ! 78 [] Not yet qualified ,% C.~ 4?tt~ <br /> NAME OF TREASURER <br /> NAME OF COMMITTEE <br /> <br /> i MAILING ADDRESS <br /> ADDRESS OF COMMITTEE NO. AND STREET CITY AREA CODE/DAYTIME PHONE <br /> <br /> CITY STATE ZIP CODE AREA CODE/PHONE NUMBER <br /> NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE <br /> <br /> COUNTY OF DOMICILE rcoumY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN <br />  COUNTY OF DOMICILE MAILING ADDRESS <br /> MAILING ADDRESS (IF DIFFERENT) NO/AND STREET OR PO. BOX CITY STATE ZIP CODE AREA CODE/DAYTIME PHONE <br /> <br /> CITY STATE ZIP CODE AREA CODE/PHONE NUMBER <br /> OPTIONAL: AREA CODE/O( NUMBER OPTIONAL: E-MAIL ADDRESS <br /> <br /> OFrlONAL: AREA CODE/FAX NUMBER OPTIONAL: E-MAIL ADDRESS <br /> Attach additional information on appropriately labeled continuation sheets. <br /> <br />3. Verification <br />I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and complete. I certify <br />under penalty of perjury un,der the laws of the State of California that the foregoing is true and correct. <br /> <br /> Executed on ~i/'[/~DAT~E By ~ "Q---"'~'-~ ~OF TREASURER <br /> Executed o. ~/[/(LF By -'-~-- /'~'"~- <br /> SIGNATURE OF CONTROLLING OFFICEHOLDER. CANDIDATE, OR STATE MEASURE PROPONENT <br /> <br /> Executed on By <br /> DATE SIGNATURE OF CONTROLLING OFFICEHOLDER. CANDIDATE, OR STATE MEASURE PROPONENT <br /> <br /> Executed on By <br /> DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT <br /> <br />FOR INFORMATION REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977. SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSURE P~IOVISIONS OF THE POLITICAL REFORM ACT <br /> FPPC Form 410 (2/98) <br /> For Technical Assistance: 916/322-5660 <br /> <br /> <br />