HomeMy WebLinkAboutFlynn, Joan L. - 2012 FPPC Campaign Disclosure Forms - Succe Recipient Committee T COVER PAGE
ype or print in ink. Date Stamp
Campaign Statement ®° �issu , ® 1
Cover Page
(Government Code Sections 84200-84216.5) 2. 2+ Page of .�
Statement covers period Date of electio 0!c,apl t- (.�
D ar.)�(Month, � For Official Use Only
from 7
SEE INSTRUCTIONS ON REVERSE through qZ3v ':90 V— C20/
t 19 I -
1. Type of Recipient Committee: All Committees-complete Parts 1,2,3,and 4. 2. Type of Statement:
Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure ❑ Preelection Statement ❑ Quarterly Statement
0 Sta Committee ❑ Semi-annual Statement ❑ Special Odd-Year Report
0 Recall 0 Controlled Termination Statement
(Also Complete Part s) Sponsored ❑ Supplemental t-Attach
tackPree Form
� P (Also file a Form 410 Termination) Statement-Attach Form 495
(Also Complete Part 6) -
❑ General Purpose Committee ❑ Amendment(Explain below)
0 Sponsored ❑ Primarily Formed Candidate/
0 Small Contributor Committee Officeholder Committee
0 Political Party/Central Committee (Also Complete Part 7)
3. Committee Information I.D. NUMBER Treasurer(s)
COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER
Joy AILING j�II� �I v/r' l v t M / 08,2 VVl�.6/a/'WT Y/`'
STREET ADDRESS P.O. BOX) CITY STATE ZIP CODE AREA COB)NNE
CI r— Y fi/t� STATE ZIP CODE �� AREA C0�4P0NE�� NAME OF ASS[ TAN TREASURER, IF ANY
II &aeA kt/
AILING ADD V
(IF DIFFERENT) NO.AND STREET OR P.O. BOX MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX/E-MAIL ADDRESS OPTIONAL: FAX/E-MAIL ADDRESS
ownP b�C Imo . Al
4. Verificati n
I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information contai d herein and in the attached schedules is true and complete. I certify
under penalty of perjury under the laws of the tate of California that the foregoing is true and correct.
Executed on By
ate Si atureofTre reror s an reasurer
Executed on By `
Date Signat re C IlingOfficeholder, did te,State surePr_op ntorResponsibleOfficerofSponsor
Executed on By (/
Date Signature of Controlling Officeholder,Candidate,State Measure Proponent
Executed on By
Date Signature of Controlling Officeholder,Candidate,State Measure Proponent
FPPC Form 460(January105)
FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772)
State of California
Type or print in ink. COVERPAGE-PART2
Recipient Committee CA LI FOR
Campaign Statement 460
Cover Page—D'art 2
Page t:;L of
5. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHOLDER OR CANDIDATE NAME OF BALLOT MEASURE
JDQA L• E cs41
OFFICE SOUGHT OR HELD(INCLUDE LOCATION AND DISTRICT NU ER IF APPLICABLE) BALLOT NO.OR LETTER JURISDICTION ❑ SUPPORT
� n ^/6 /) ❑ OPPOSE
RES I D ENTIAL(&9INESS ADDRESS (NO.AND STREET) CIT STATE ZIP
p� Identify the controlling officeholder, candidate, or state measure proponent, if any.
NAME OF OFFICEHOLDER,CANDIDATE,OR PROPONENT
Related Committees Not Included in this Statement: List any committees
not included in this statement that are controlled by you or are primarily formed to receive OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
contributions or make expenditures on behalf of your candidacy.
COMMITTEE NAME I.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE? 7• Primarily Formed Candidate/Officeholder Committee List names of
officeholder(s) or candidate(s)for which this committee is primarily formed.
❑ YES ❑ NO
COMMITTEE ADDRESS STREET ADDRESS (NO P.O.BOX) NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
COMMITTEE NAME I.D. NUMBER
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT
❑ OPPOSE
NAME OF TREASURER CONTROLLED COMMITTEE? NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ YES ❑ NO ❑ SUPPORT
❑ OPPOSE
COMMITTEE ADDRESS STREET ADDRESS (NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE Attach continuation sheets if necessary
FPPC Form 460(January105)
FPPC Toll-Free Helpline:8661ASK-FPPC(866/275-3772)
State of California
a e.
Campaign Disclosure Statement Type or print in ink. SUMMARY PAGE
Amounts may be rounded Statement covers period
Summary Page to whole dollars. CALIFORNIAI
from �" FORM
SEE INSTRUCTIONS ON REVERSE I
through sC Page� of 3
NAME OF FILER I.D.NUMBER
Column A Column B Calendar Year Summary for Candidates
Contributions Received TOTALTHISPERIOD CALENDAR YEAR Running in Both the State Primary and
(FROM ATTACHED SCHEDULES) TOTALTO DATE g
��. General Elections
1. Monetary Contributions ........................................... schedule A,Line 3 $ �� $
1/1 through 6/30 7/1 to Date
2. Loans Received ...................................................... Schedule a,Line 3
3. SUBTOTAL CASH CONTRIBUTIONS ......................... add Lines 1+2 $ $ 20. Contributions�' Received $ $
4. Nonmonetary Contributions.................................... Schedule C,Line 3 '� 21. Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED ...........................Add Lines 3+4 $ $ Made $ $
Expenditures Made Expenditure Limit Summary for State
6. Payments Made....................................................... schedule E,Line 4 $ r $ Candidates
7. Loans Made............................................................. schedule H,Line 3
22. Cumulative Expenditures Made*
8. SUBTOTALCASH PAYMENTS .................................... add Lines 6+7 $ ,r $ .� (If Subject to voluntary Expenditure Limit)
9. Accrued Expenses (Unpaid Bills)...............................schedule F,Line 3 .Q'/ ��� Date of Election Total to Date
10. Nonmonetary Adjustment ..........................................ScheduleC,Linea (mm/dd/yy)
11. TOTAL EXPENDITURES MADE................................Add Lines 8+9+10 $ $ $
Current Cash Statement J $
12. Beginning Cash Balance....................... Previous Summary Page,Line 16 $
To calculate Column B,add
13.Cash Receipts ................................................... Column A,Line 3 above amounts in Column A to the
corresponding amounts *Amounts in this section may be different from amounts
14. Miscellaneous Increases to Cash........................... schedule I,Line 4 from Column B of your last reported in Column B.
15.Cash Payments.................................................. Column A,Line 6above -� report. Some amounts inColumn A may be negative
16.ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ figures that should be
subtracted from previous
If this is a termination statement, Line 16 must be zero. period amounts. If this is
the first report being filed
17. LOAN GUARANTEES RECEIVED........................... schedule a,Part 2 $ for this calendar year, only
carry over the amounts
Cash Equivalents and Outstanding Debts an
Lines 2,7,ands(if
y)
18. Cash Equivalents........................................ See instructions on reverse $ �J
19. Outstanding Debts......................... Add Line 2+Line 9 in Column a above $ FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
Statement of Organization STATEMENT OF ORGANIZATION
Type or print in ink Date Stamp ,_i
Recipient Committee < ® '
Statement Type ❑Initial ❑ Amendment Termination—See Part 5 { SEP yk, For Official Use Only
Not yet qualified El or
List I.D.number: List I.D.number. ��[ ' f � .+ '7
Date qualified as committee Date qualified as committee Date of Termination
(If applicable) -
1. Committee Information 2. Treasurer and Other Principal Officers
NAME OF COMMITTEE NAMJ OF TREASURER
I �} 6?lltow-
STREETADDRESS(NO P. . OX)
�JOQ n r1vr!n c' C� i O p`
STREETADDRESS(NO P. BOX) CIT STATE ZIP CODE AREA COQEJPHIPNE
CITY STATE ZIP CODE AREA COD�%NM T N E OF ASSIST REASURER,IF ANY
�� STREETADDRESS(NO P.O.BOX)
MAILING ADDR SF DIFFERENT)
CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX/E-MAILADDRESS
/r G �� �� ,✓1 NAME OF PRINCIPALOFFICER(S)
COUNTY OF OOMICILE COUNTY WHERE CO MITTEE IS ACTIVE IF/DIFFERENT
THAN COUNTY OF D MICILE STREET ADDRESS(NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE ,
Attach ad ronal information on appropriately labeled continuation sheets.
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained her ' is true and complete. I certify under penalty of
perjury under the laws of the State of alifornia that the foregoing is true and correct.
Executed on By
A E TLIRE OFT S ASSISTANTTREASURER
Executed on Z By
PATE NATURE OF CORTROLLING OFFICEHOL ANDIDATE,OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT
FPPC Form 410 (April/2011)
FPPC Toll-Free Helpline: 866/ASK-FPPC (8661275-3772)
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee ,CALIFORNIA
. -
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D.NUMBER
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.
ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
Pleo -/V/) GQ on-Partisan
❑ Non-Partisan
• List the financial institution where the campaign bank account is located (controlled"candidate election"committees only)
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANKACCOUNT NUMBER
. AO/A I
ADDRESS CITY STATE ZIP CODE
r 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
SUPPORT OPPOSE
FPPC Form 410 (April/2011)
FPPC Toll-Free Helpllne: 866/ASK-FPPC (8661275-3772)
r '
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Corlr>trlr>tittee ZALIFORNIAa 0
FORMI
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D.NUMBER
• �e rk oolak_ / v
4.Type of Commlittee (Continued)
o a . 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 OFACTIVITY
o List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREETADDRESS NO.AND STREET CITY STATE ZIP CODE
0 o e e
❑
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 (866/275-3772)
Recipient Committee Type or print in ink. Date Stamp
Cover Page E-filed on: l
(Government Code Sections 84200-84216.5) I
Statement covers period Date of election if appQ*?:FJL. 3' 1 Pflipage 1 of 3
01/01/2012 (Month, Day, Year)
from For Official Use Only
SEE INSTRUCTIONS ON REVERSE through 06/30/2012 06j
1. Type of Recipient Committee: All committees-Complete Parts 1,2,3,and 4. 2. Type of Statement:
❑x Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure ❑ Preelection Statement ❑ Quarterly Statement
Q State Candidate Election Committee Committee ❑x Semi-annual Statement ❑ Special Odd-Year Report
Q Recall Q Controlled
(AlsoComp/etePart5) Sponsored ❑ Ter ❑ Supplemental Preelection
P (Also file a Form 410 Termination) Statement-Attach Form 495
❑ General Purpose Committee (Also Complete Part 6) ❑ Amendment(Explain below)
0 Sponsored ❑ Primarily Formed Candidate/
0 Small Contributor Committee Officeholder Committee
0 Political Party/Central Committee (Also Complete Part7)
3. Committee Information I.D. NUMBER Treasurer(s)
1348181
COMMITTEE NAME(OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER
Joan Flynn for City Clerk 2012
Joan Fly
ILING ADDRESS l/
�P0$� Ile�2on�'c D/e- &at, ;eac,� CfF 9,;t4`&
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
9082 Veronica Drive
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
Huntington Beach CA 92646 (714) 615-9957
MAILING ADDRESS (IF DIFFERENT) NO.AND STREET OR P.O. BOX MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX/E-MAIL ADDRESS OPTIONAL: FAX/E-MAIL ADDRESS
'oanflynn4hbcityclerk@yahoo.com
4. Verification
I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information co tained herein and in the attached schedules is true and complete. I certify
under penalty of perjury under the laws of the State of California that the foregoing is true an ect.
Executed on ��/z a B
Date Si atureofTreasu Assistant Treasurer
Executed on � �� B2----:Sign Date' u f Controlling old r,Candida e,Slate a sure Proponent or Responsible Officer of Sponsor
Executed on By
Date Signature of Controlling Officeholder, ndidate,State Measure Proponent
Executed on By
Date Signature of Controlling Officeholder,Candidate,State Measure Proponent FPPC Form 460(January105)
FPPC Toll-Free Helpline:8661ASK-FPPC(866/275-3772)
State of California
Type or print in ink. COVER PAGE-PART 2
Recipient Committee CALIFORNIA '
Campaign Statement OR 4 • 1
Cover Page—Part 2
Page 2 of 3
5. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHOLDER OR CANDIDATE NAME OF BALLOT MEASURE
Joan Flynn
OFFICE SOUGHT OR HELD(INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) BALLOT NO.OR LETTER JURISDICTION ❑ SUPPORT
❑ OPPOSE
City Clerk Huntington Beach Huntington Beach
RESIDENTIAL/BUSINESS ADDRESS (NO.AND STREET) CITY STATE ZIP
�} /� � }� ]��� �f �I Identify the controlling officeholder, candidate, or state measure proponent, if any.
'v R 2- Le-Mili,CA jre`�'�" _- �� " ak "� NAME OF OFFICEHOLDER,CANDIDATE,OR PROPONENT
Related Committees Not Included in this Statement: List any committees
not included in this statement that are controlled by you or are primarily formed to receive OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
contributions or make expenditures on behalf of your candidacy.
COMMITTEENAME I.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE? 7• Primarily Formed Candidate/Officeholder Committee List names of
officeholder(s)or candidate(s)for which this committee is primarily formed.
❑ YES ❑ NO
COMMITTEE ADDRESS STREETADDRESS (NO P.O.BOX) NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
COMMITTEE NAME I.D. NUMBER
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT
❑ OPPOSE
NAME OF TREASURER CONTROLLED COMMITTEE? NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ YES ❑ NO ❑ SUPPORT
❑ OPPOSE
COMMITTEE ADDRESS STREETADDRESS (NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE Attach continuation sheets if necessary
FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
State of California
Campaign Disclosure Statement Type or print in ink. SUMMARYPAGE
Amounts may be rounded Statement covers period CALIFO-
Summary Page to whole dollars. 1
from 01/01/2012 FORM,
SEE INSTRUCTIONS ON REVERSE through 06/30/2012 Page 3 of 3
NAME OF FILER I.D. NUMBER
Joan Flynn for City Clerk 2012
1348181
TColumn
of HimP oD Column B Calendar Year Summary for Candidates
Contributions Received Runningg in Both the State Primary,and
(FROM ATTACHED SCHEDULES) TOTALTO DATE '7
General Elections
1. Monetary Contributions ........................................... Schedule A,Linea $ $0.00 $ $0.00 1/1 through 6/30 7/1 to Date
2. Loans Received ...................................................... Schedule B,Line 3 $0.00 $0.00
3. SUBTOTALCASH CONTRIBUTIONS ......................... Add Lines 1+2 $ $0.00 $ $0.00 20. Contributions
Received $ $
4. Nonmonetary Contributions.................................... Schedule C,Line 3 $0.00 $0.00 21. Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED ...........................Add Lines 3+4 $ $0.00 $ $0.00 Made $ $
Expenditures Made Expenditure Limit Summary for State
6. Payments Made....................................................... Schedule E,Line 4 $ $0.00 $ $0.00 Candidates
7. Loans Made............................................................. Schedule H,Line 3 $0.00 $0.00
22. Cumulative Expenditures Made*
8. SUBTOTALCASH PAYMENTS .................................... Add Lines 6+7 $ $0.00 $ $0.00 (If Subject to Voluntary Expenditure Limit)
9. Accrued Expenses (Unpaid Bills)...............................Schedule F Line 3 $0.00 $0.00 Date of Election Total to Date
10. Nonmonetary Adjustment ..........................................Schedule C,Line 3 $0.00 $0.00 (mm/dd/yy)
11. TOTAL EXPENDITU RES MADE................................Add Lines a+9+10 $ $0.00 $ $0.00 $
Current Cash Statement $
12. Beginning Cash Balance....................... Previous Summary Page,Line 16 $ $0.00 To calculate Column B,add
13.Cash Receipts ................................................... Column A,Line 3 above $0.00 amounts in Column A to the
corresponding amounts *Amounts in this section may be different from amounts
$o.oo
14. Miscellaneous Increases to Cash........................... schedule 1,Line 4 from Column B of your last reported in Column B.
00 report. Some amounts in
15.Cash Payments.................................................. Column A,Line 6 above $0. Column A may be negative
16. ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ $0.00
0.00 figures that should be
subtracted from previous
If this is a termination statement, Line 16 must be zero. period amounts. If this is
the first report being filed
17. LOAN GUARANTEES RECEIVED........................... Schedule B,Part 2 $ $o.oo for this calendar year, only
carry over the amounts
Cash Equivalents and Outstanding Debts an
Lines 2,7,and 9(if
$o.00 y).
18. Cash Equivalents........................................ See instructions on reverse $
19. Outstanding Debts......................... Add Line 2+Line 9 in Column B above $ $0.00 FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
Statement of Organization Stamp; STATEMENT OF ORGANIZATION
Type or print in ink Date -
Recipient Committee � PorOfficial
- dStatement Type �nitial ❑ Amendment `� °' t l
❑ Termination-See Part 5 L d �,i( ;; C Pit ,� Use Only
ified or List I.D.number: List I.D.number:
# #
If
Date qualified as committee Date qualified as committee Date of Termination
(If applicable)
1. Committee Information 2. Treasurer and Other Principal Officers
NAME OF COMMITTEE NA E OF TREASURER
REETAD
)oq,�, �c'/J/l 40t�l o�� STnt/ 0-SS(NV��-{Jj 1
S t 7 d Box)
C-A �/2�y
CITY STATE ZIP CODE AREA CODE/PHONE 9
CITY STATE ZIP CODE AREA CODE/PHQONNE NAME OF AS IST T TREASURER,IF ANY
#u0�� nCj�� � ` �� � /� /�-" "�� STREET ADDRESS(NO P.O.BOX)
MAILING AD at (IF DIFFERENT)
CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX/E-MAIL ADDRESS
Oak_rl I Iso A ya Lon . n NAME OF PRINCIPALOFFICER(S)
OUNTY OF I)OMICILE CO NTY WHERE COMM11TEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE STREETADDRESS(NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
Attach additional information on appropriately labeled continuation sheets.
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained erein is true and complete. I certify under penalty of
perjury under the laws of the State of California that the foregoing is true and correct.
Executed on �- By aa,2!2L2(\,--
j,
D T --SIG ATUR OFTRE ER OR ASSISTANT TREASURER
Executed on By
E I ATURE OF CON LING OFF110ENO 71
D CA I ATE,OR STATE MEASURE PROPONENT
Executed on By
DATE SIG ATURE OF CONTROLLING OFFICEHOLIMR,CANDIDATE,OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT
FPPC Form 410 (April/2011)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee ® - a �
®-
INSTRUCTIONS ON REVERSE
Page 2
COM ITTEE NAME �7 I.D.NUMBER
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.
e List the political party with which each officeholder or candidate is affiliated or check"non-partisan."
o 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
4(-7 / Gr—won-Partisan
L • .' /� moo/
❑ Non-Partisan
o List the financial institution where the campaign bank account is located(controlled"candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREACODE/PHONE BANKACCOUNTNUMBER
ADDRESS CITY STATE ZIP CODE
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
SUPPORT OPPOSE
FPPC Form 410 (April/2011)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee �'.�QALIFOANIA
6 441
-
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D.NUMBER
Joa�a or- a
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 INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREETADDRESS NO.AND STREET CITY STATE ZIP CODE
❑
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: 8661ASK-FPPC (8661275-3772)