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Statement of Organization <br /> STAT EMENT O F O R. GANIZATIO N <br />Recipient Committee Type m' pi'tnt In Ink · ,'O~teStamp.. <br /> <br />Statement Type [] Initial mendment [] Termination - See Part 5 " <br /> Notyetquallfied [-] or / Lts~J.D. number.. List I.D. .umber: '. OCT ~ 5 <br /> ..... <br /> // <br /> , ,.__ ,01 , , <br /> Data qualified as committee Date qualified as committee Data of Termination <br />~. Committee Information 2. Treasurer and Other Principal Officers <br /> <br /> STREET ADORESS (NO P.O. BOX) <br /> <br /> MAILING ADDRESS (IF DIFFERENt') ~- STREET ADDRESS <br /> <br /> CITY STATE ZIP CODE AREA CODE/PHONE <br /> SS <br /> ~OUNTY OF DOMICILE COUNTY WHERE COMMI'FrEE IS ACTIVE IF DIFFERENT <br /> <br /> At~achadditionalinformationonappropdatelylabeledcoNtinuatioNsheets. CiTY STATE ZIP CODE AREA CODE/PHONE <br /> <br /> 3. Verification <br /> [ have used all reasonable dilige nt and to the best of my knowledge the~t~lormation contained herein is true and complete. I certify under penatty of <br /> perjury under the laws of the State of California that the foregoing is true and correct. / ~/~ ~ <br /> Executed on b-- ~ V-~/ By /~a "' /ll~J~ <br /> DATE RE <br /> -.-- / t'liJ,I . / ~' ~"~U OFTREASURERORASSISTANTTREASURER <br /> ~x.~ed~ /~-- 4 ¥-~t <br /> / <br /> <br /> DATE SIONATURE OF coNTROLLING OFFICEHOLDER. CANDIDATE, OR STATE MEASURE PROPONENT <br /> Executed on By <br /> DATE $1GNAI~,J RE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT <br /> <br /> FPPC Form 410 (Jan/01) <br /> FPPC Toll-Frae Hell]line: 8eBIASK-FPPC <br /> <br /> <br />