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Z/ / STATEMENT OF ORGANIZATION <br />Statement of Or g anizat,o. WIlE RE TO FILE: Date Stamp <br />Recipient Committee S eoetaryFile original and one copy of this fo,m with:of S,~te RECEIVED <br />(Government Code Secuons 8~ 101-84103) Pohtical Reform Division AND FILED ......... ~or Off<,~e O~ly <br /> P O B ox 1467 ~n the ~e ~ the ~reto~ ~ <br /> Amendment Sacramento. CA 95812-1467 ~ the State of ~li~ni. <br /> <br /> ~ Check box if an Amendment And, if applicable, file one copy of this form with: <br />~ype or Print in lnk anden,erl~ number. ~he c,,y or county o,f,cer. ,f any. who rece,ve, 'he ~ 0 ~ <br /> rommittee'~ original campaign <br /> ~ qZ ITbq statements. <br />SEE INSTRUCTIONS ON REVERSE <br />I Committee Information II Treasurer and Other Pri~~ ~ <br /> NAME OF TREASURER,: <br /> <br /> Committee: tMonth, Day, Year} <br /> MAILING ADDRESS: <br /> <br /> CITY S~ATE ZIP CODE AREA CODE/DAYTIME PHONE <br /> <br /> NAME AND e~LTJOU OFBTHER PRIN[IP~L OFFiCER(S): <br /> <br /> COUNTY OF DOMICILE: J COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT ~,~ ~ <br /> J1HANCOUNTYOFDOMICI E: <br /> CITY STATE ZIP CODE AREA CODE/DAYTIME PHONE <br /> MAIL lNG ADDRESS: (IF DIFFERENT) NO AND STREETOR(~O BOX <br /> <br /> CITY STATE ZIP COD:--' AREA CODE/PHONE NUMBER Attach additional information on appropriately labeled continuation <br /> sheets. <br /> <br /> III Disposition of Surplus Funds You must specify wt~at disposition will be made of leftover campaign funds, if any, at termination. <br /> <br /> IV Verification <br /> I I~ave used all reasonable diligence in preparing this statement and to the best of my knowledge tl?~nform~ion [qon~ined herein is true and complete. I <br /> cer~ifyunder~e~a~ty~fper~uryunderthe~aws~ftheState~`fCa~if~rniathatthef~reg~ingistrue~n~c~r`¢~ ~ - . <br /> <br /> DATE CiTY AND ~I~E~ ~ <br /> Executed on At By 51GNAIURE Of CONTROLLING OFFICEHOLDER, CANDIDATE, OR SLATE ME ~SURE PROPONEN1 <br /> D~TE CITY AND STATE <br /> <br /> Executed on At By <br /> DAIE ~ CITY AND SLATE SIGNAItJflE OF CONIROLLING OFFICEHOLDER. CANDIDAIE, OR SLATE MEASURE PROPONENT <br /> <br /> Executed On. At By SIGNATURE OF CONIROLLING ()FFICEHO[OER. CANDIDA1E. OR STATE MEASURE PROPONENT <br /> DAlE CITY AND 5IA~E <br /> <br /> State of California Fair Political Practkes Commission <br /> <br /> <br />