2010-11-29 Form 410 - PS Fire ManagementStatement of Organization
Recipient Committee Type or print in ink Date Stamp
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STATEMENT OF ORGANIZATION
CALIFORNIA 41 0
FORM
Statement Type D Initial ~ Amendment D Termination -See Part 5 For Official Use Only
Not yet qualified O or List t.D. number: List I.D . number: 010 N 1.' 29
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Date qualified as committee Date qualified as committee
(If applicable)
Date of Termination
STREET ADDRESS (NO P.O. BOX)
COUNTY OF DOMICILE
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ZIP C ODE AREA C ODE/PHONE
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COUNTY WHERE C OMMITTEE IS AC TIVE IF DIFFERENT
THAN CO UNTY OF DOMICILE
Attach additional information on appropriately labeled continuation sheets.
3. Verification
2. Treasurer and Other Principal Officers
N~ OF TREASURER ,..
(Lt2 0 df dn C\ ~
AREA CODE/PHONE t:\1~ ~ 1.'2-&,'-f
NAME OF ASS I STAN
STREET A DDRESS (NO P.O. BOX)
C ITY STATE ZIP CODE AREA CODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET A DDRESS (NO P.O . BOX )
CITY STATE Z IP COD E AREA CODE/PHON E
I have used all reasonable diligence in preparing this statement and to the best of my kn
perjury under the laws f th e State of Ca lifornia that the foregoing is true and correct.
w ledge the information contained herein is true and complete . I certify under penalty of
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ATE
Executed on
DATE
Executed on
DATE
Executed on
DATE
By
By
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (Junel 09)
FPPC Toll-Free Helpline: 866IASK-FPPC (8661275-3772)
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Statement of Organization
Recipient Committee
INSTRUCTIONS.ON REVERSE
COMMITTEE NAME
4. Type of Committee Complete the applicable sections.
Controlled Committee
STATEMENT OF ORGANIZATION
CALIFORNIA 41 0
FORM
I.D. NUMBER
• 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 APRLlCABLE)
• List the financial institution where the campaign.bank account is located (COntrolled ~candidate election" committees only)
YEAR OF ELECTION
N~E OF Fl~NCIAL INSTITUTION "h (iii." I, J AREA CODE/PHONE BANK ACCOUNT NUMBER
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ADDRESS CITY STATE ZIP CODE
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Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(~) NAME OR MEASURE($) 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)
PARTY
D Non-Partisan
D Non-Partisan
CHECK ONE
I~~ ~-=,
RT OPPOSE
FPPC Form 410 (June/09)
FPPC Toll-Free Helpline: ·866/ASK-fPPC (866/275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
STATEMENT OF ORGANIZATION
CALIFORNIA 410
FORM
COMMITTEE NAME I.D. NUMBER
4. Type of Committee (Continued)'
General Purpose Committee 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
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 •--~-~--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 (June/09)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)