2019-10-23 Form 410 - Palm Springs ForwardRE CEIVE D
CI T y OF p ALM SPRING S
2019 OCT 23 p
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D•te Slllmp Statement of Organization
Recipient committee OF FICE OF THE /TY CLE H
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10 15 2019
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1. Committee Information I.D. Number
(If appl/cable) 1399254
'1,AMC9lCO~~JTIEE Pa1rn ::;pnngs Forward
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Co!Y STA.fE llP COO'f IJl[A COO C/PHONE
Palm Springs CA 92261
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l--MAIL AOOIIUS llll(QUllllDI / f•JC jQ,TIONAll
COUNl"1 or DOM.OU JUIU501CTION WHUf C0'4MITTU ISACTIVC
Attach oddltfonal Information on appropri ately labeled continuation sheers.
3 . er cation
Dale of lerminaUon
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2. Treasurer and Other Principal Officeh
' HAM ( Of: TREAlUIUII
John Shay
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CITY $1ATE
Palm Springs, CA
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CALIFORNIA 41 Q
FORM
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I have used all reasonable diligence In preparing this
Executed on {O .2-3 I
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Executed on By
DAI[ SIGHAU#llf Of C0HJPIOUIN6 OHIClHO'-Df"-CANOIOAJE, Oft ltAlf MlASU'l:l ,ill;OPONl"fl
Execu ted on By
DA.TE SIONAHJIU or CONIIIOWNGOrllCfUOlO(R.,. CANOIOATf.011 :l,141[ MlAWftf JIIIOJIOH[N1
Extt<u led on By
DAIi Sl(,NATUII( Of CONfAOU11'G OHl((HOLOU. CANOIOAt[. Qfl ,u,1 r MFAWltl ,110,oN[NI
FPPC For m 410 (August/2018)
FPPC Advice: advlce(§lf p pc.ca.gov (866/275,3772)
www.fp pc.ca.gov
Statement of Organization
Recipient Committee CALIFORNIA 41 Q
FORM
INSTRUCTIONS ON REVERSE
c~1fWS'p~~gs Forward
• All committees must 11st the financial Institution where the campaign bank account Is located.
NAM£ o, FINANCIAUNSTITUTION ARJ:ACOCE/l'HON! DANK ACCOUNT NUMBER ' Pacific Premier Bank 760 9694555 171795775
ADDRESS STATf 11? CODE
901 East Tahquitz Canyon Way Palm Springs CA 92262
•Controlled Committee
• List the name of each controlllng 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 polltlcal party with which each officeholder or candidate Is affillated or check "nonpartisan." Stating "No party preference" Is acceptable.
• If thls committee acts jo!ntly with another controlled committee, 11st the name and Identification number of the other controlled committee.
NAME OF CAND!DATE/OFFICEl!OLDER/STATE MEASURE PROPONENT
ELECTIVE OFFIC:E SOUGHT OR HELD
(INC WOE DISTRICT NUMBER JF APPLICABLE]
YEAR OF
EL£CTION
PARTY
CHECK ONE
Nonpartisan Partisan • • Nonpartisan Partisan • •
Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures In a single election. List below:
CANDIDATE{SJ NAME OR MEASURE(S) FULL TITLE (INC:LUDE BALLOT NO.OR LmERI
IF A RECAl.l, STATE "RECALL" IN· FRONT OFT HE OFFICEHOLDER'S NAME,
CAND10ATE(SJ OFFICE SOUGHT OR HELO ORM EASURE(SI JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE!
(1Jst polltkal party below)
1st podtlcal party ue10w1
J
FPPC Form 410 (AUgUst/2018)
FPPC Advice: advlce@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON RtV£RSE
CALIFORNIA 41 0
FORM
1.0.liUMDER
1399254
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~Type_of Committee_ · __ ·1eont1nued)_ ... ---------·-... _, __ -·--·---·--------------------____ -' '~·· ____ _ ______ J
' , ...... _: ....
General Purpose Committee Not formed to support or oppose specific candidates or measures in a slngle election, Check only one b~xt: _, ·
li2I CITY Committee D COUNTY Committee D STATE Committee \
PROVIOa llRIEJ OESCRlPTION Of AITIV/TY
Sponsored Committee List additional sponsors on an attachment,
NAMS Of SPONSOR INOUSTJn' GROUP Oil MflUATIOtl OJ SPON1011.
STREET ADDRESS NO. AND STREET '"' STAte ZlPCDDl A.REA CDDf/PIIDNE
Small Contributor Committee
S. Termination Requirements-· .. By SJgnlns tho_verificatlon;thll trea~urer, ass!siant treasurerilni:1/of Glndtdate, offlcehOldar, or proponei,t certify that all ofthii" f0110Wlng conditions_ ha°ve. bee!\ met:. · .. , ··-J
Thls committee has ceased to receive contributions and make expenditures;
Thls committee does not anticipate receiving contributions or making expenditures In the future;
This committee has elimlnated or has no Intention or ablllty to discharge all debts, loans received, and other oblfgatlons;
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 (August/2018)
FPPC Advice: advlce@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov