HomeMy WebLinkAboutPolsky, Alexander S. - 2013 FPPC Campaign Disclosure Forms f (7)Statement of Organization
Recipient Committee
STATEMENT OF ORGANIZATION
INSTRUCTIONS ON REVERSE
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COMMIT E NAME I.D. NUMBER
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4. Type of Committee Complete the applicable sections.
• List the name of each controlling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled, also list the elective office sought or held, and
district number, if any, and the year of the election.
• List the political party with which each officeholder or candidate is affiliated or check "non -partisan."
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE) .YEAR OF ELECTION PARTY
Non -Partisan
❑ Non -Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREACODE/PHONE BANKACCOUNTNUMBER
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ADDRESS ' I CITY �j STTA—TlE� ZIP CODES 4Tr,1
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e • . e Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT OPPOSE
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FPPC Form 410 (April/2077)
FPPC Toll -Free Helpllne: 866/ASK-FPPC (866/275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
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4. Type of Committee (Continued)
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors on an attachment.
NAME OF SPONSOR
STREETADDRESS NO. AND STREET
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STATE ZIP CODE
STATEMENT. OF ORGANIZATION
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e e e e
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Date qualified
5. Termination RequirementS By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent certify that all of the following conditions have been met:
• This committee has ceased to receive contributions and make expenditures;
• This committee does not anticipate receiving contributions or making expenditures in the future;
• This committee has eliminated or has no intention or ability to discharge all debts, loans received, and other obligations;
• This committee has no surplus funds; and
• This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions.
-- There are restrictions on the disposition of surplus campaign funds held by elected officers who are leaving office and by defeated candidates. Refer to
Government Code Section 89519.
-- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511 -
89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410 (April/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772)