2002-09-26 Form 410 - PS Fire Management< -..
Statement of Organization
Recipient Committee
Statement Type Bfnitial
Not yet qualified D or
33 Type or print In Ink
0 Amendment
Li st I.D. numbe r:
# _______ _
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Date qualified as committee Dat e qualified as committee
(~ applicable)
1. Committee Information
NAME OF COMMITTEE
0 Termination -See Part 5
List I.D. number:
# _______ _
2 . Treasurer and Other Principal Officers
NAME OF TREASURER
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STREET ADDRESS
STATEMENT OF ORGAN IZATION
CALIFORNIA 41 0
FORM
For Official Use Only
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CITY
OPTIONAL: FAX/ E-MAIL ADDRESS
COUNTY OF DOMICILE
STATE ZIP CODE AREA CODE/PH ONE
C A-
COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
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NAME OF ASSISTANT T~EASU. IF ANY
STREET ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
MAILING ADDRESS
CITY STATE AREA CODE/PHONE
~ttach additional informa tion on appropriately labeled continuation sheets.
ZIP COD~
3. Verification
I have used all reasonable diligence in preparing this statement and to the
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( DATE /
Executed on
DATE
Executed on
DATE
Executed on
DATE
By--------------:-----------.,,...,---------------------,---,------------SIGNATURE OF CONTROLLING OFFICEHOLDER. CANDIDATE. OR STATE MEASURE PROPONENT
By _____________________________________ _
SIGNATURE OF CONTROLLING OFFICEHOLDER. CANDIDATE. OR STATE MEASURE PROPONENT
By ______ --:c:==-::====~==,,,,..,,=="'====-=-::-::,=~~=--==,=,-,,=------s1GNATURE OF CONTROLLING OFFICEHOLDER. CANDIDATE. OR STATE M EASURE PROPONENT
FPP C For m 41 0 (Ja nl01)
FPPC To ll-Free Helpline: 866/A SK -FPPC
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Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
:5 Fi,e
4. Type of Committee (Continued)
C,
General P.urpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
[B-'c!TY Committee D COUNTY Committee •-STATE Committee
STATEMENT OF ORGANIZATION
CALIFORNIA 410
FORM
1.0.NUMBER
>ROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE
Small Contributor Committee D __ _,~---Check box and provide the date this committee qualified as a small contributor committee. If the committee qualified as a small
Date qualified contributor committee on January 1, 2001, enter 1/1/01.
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 co_ntributions 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.
--Additional filing obligations will be incurred if, after terminating, the committee receives or spends any funds, or receives the forgiveness of a loan,
repayments of loans made to others, or any other receipts.
FPPC Form 410 (Jan/01)
FPPC Toll-Free Helpline: 866/ASK-FPPC