HomeMy WebLinkAboutDan Carpenter - Form 410 - Termination 01-04-2012Statement of Organization
Recipient Committee
Statement Type ❑ Initial
Not yet qualified ❑ or
Date qualified as committee
1- Committee Information
NAME OF COMMITTEE
Type or print in ink
❑ Amendment
List I.D. number:
f. —I
Date qualified as committee
(If applicable)
K --er fns S t-p G
ermination — See Part 5
List I.D. umber:
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Date of Termination
Date Stamp u I 'a
In Ivc. ) +
of r
JAN 08 2013
DEE
2. Treasurer and Other
rincipal Officers
NAME OF TREASURER
Zn
STREET
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A I I'[tt 4 AUUIttS�(NU Y.U. jo Ve
CITY STATE ZIP CODE AREA CODE /PHONE
CIL
MAILINGADDRESS (IF DIFFERENT)
OPTIONAL: FAX / E- MAILADDRESS
da N Ca r12 s L.Q 4.AWo . C C) &i,,
COUNTY OF DOMOtILE COUNTY WHERE COMMITTEE ISACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
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Attach additional information on appropriately labeled continuation sheets.
STATEMENT OF ORGANIZATION
• - AIA ,
I
:-or Official Use Only
(NO P.O. BO
X/0 A/I S�ti uP
STATE ZIP CODE AREACODE /PHONE
Two 9,3 t 15-r TO �e-�
NAML OF ASSISTANT TREASURPR, IF ANY
^� /STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREACODE /PHONE
NAME OF PRINCIPAL OFFICER(S)
STREETADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREACODEIPHONE
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information co ed herein is true and complete. I certify under penalty of
perjury under the laws of th State # California that the foregoing is true and correc .
Executed on By
,r A E SI GIN A F R OR ASSISTANT TREASURER
Executed on / Q s f B
��� y
4��(DATE
URE OF C ROLLPNC; ❑ _ nnic no crax uce¢ eoc ner,on.ur.,r
Executed on B i /
DATE y
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE. OR STATE MEASURE PROPONENT
Executed on By
DATE IGNATU E OF CONTROLLING OFFICEHOLDER, ANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (April /2011)
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