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HomeMy WebLinkAboutJan Marx Form 410 - Initial - 04-23-2012q13 Statement of Organization Recipient Committee Statement Type �nitial Not yet qualified ❑ or D If i �-3 r _-20 /v Date qualified as committee 1. Committee Information 4ME OF COMMITTEE �� ��� STATEMENT OF ORGANIZATION Type or print in ink � �. Date Stamp _ RE EIVED AND FILE 1 ❑ Amendment ❑ Termination — See Part 516 th 01 flee a# the Of Cglifor QI of the State of Call #ornla Fpr O�cia[ Use Only List I.D. number: List I.D. number: i I Date qualified as committee (If applicable) 7 aLL.. It ta+'X 41- ' or a0 / z 2Co S zn`,..a CITY STATE ZIP CODE AREA CODEIPHONE .�_ L"s ©b. ' o G4 'f3 KO S MAILIN DDRESS (IF DIFFERENT) '0- x / OPTIONAL: FAX 1 E -MAIL ADDRESS /CIAMa0( psi- anrre(aILi t,('. o COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE Sans C��. S Saner Attach additional information on appropriately labeled continuation sheets. APR 2 5 2012 I EERA EOWEN Date of Termination Secretary of State 2. Treasurer and Other Principal Officers NAME F TREASURER STREET ADD R SS( P.O. BOX) CITY ✓� STATE ZIP CODE AREA CODEIPHONE -�c, s �hi3 O v_1 3 yv� $ys 3 y) - Z j 7 NAME OF ASSISTANT TREASURER, IF ANY ,aln AAa r- >c NAME OF PRINCIPAL OFFICER(S) ran /Vla roc C-4- 3 �eo_s" �--- "3- 0LQ? o C,4 fi 3 F J,' 3. Verification I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and complete perjury under the laws Of the State of California that the foregoing is true ar Executed on q— Z-3-12- By DAT E Executed on — g DATE y Executed on DATE Executed on DATE By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT I certify under penalty of By 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 Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE -J jNNAME Q ✓l Ala rx � /LtQy or O / 2 4. Type of Committee Complete the applicable sections. Controlled Committee STATEMENT OF ORGANIZATION 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 CAN DIDATEIOFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY 1�Q Non- Partisan h �� 20 / 2 ❑ Non - Partisan • List the financial institution where the campaign bank account is located (controlled "candidate election" committees only) NAME OF FINANCIAL INSTITUTIO �n dQ.e. +(- 'S 1 AREA CODEIPHONE �� ADDRESS CITY STATE ZIP CODE �G 3 /t't afs/, s'f-. �S'ah Ct,L,r OLI' JFID q 3 �o f • . 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 IOPPOSE D FPPC Form 410 (April/2011) FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772) S- atement of Organization Recipient Committee Statement Type �nitial Not yet qualified ❑ or o 'fJ,?.70/ Date qualified as committee 1. Committee Information - NAME OF COMMITTEE 2(oS /4(47e/ - Type or print in ink ❑ Amendment List I.D. number: 1 Date qualified as committee (If applicable) 20 / Z mp ❑ Termination — See Part 5 List I.D. number: CITY STATE ZIP CODE AREA CODE /PHONE 5e-- 4 ,s ©LIVo c,4 y'3 Ko s MAILIN DDRESS (IF DIFFERENI 0. aox OPTIONAL: FAX/ E- MAILADDRES an man( COUN7f OF DOMICILE Ltt,s 06,E S4 an r- a1LJMrtl', o COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE o S�� Date of Termination 2. Treasurer and Other Principal Officers NAME F TREASURER STREETADDR SS (VID P.O. BOX) STATEMENT OF ORGANIZATION For Official Use Only RECEIVED APR 2 1 2012 SLO CITY CLERK CITY LL ✓� STATE ZIP CODE -7 NAME OF ASSISTANT TREASURER, IF ANY - aln 1A0-r)C 0�apo C rf C,--1- :F3 tfO NAME OF PRINCIPAL OFI 3-an Ma V-X dTfV_,,AP1 007 Attach additional information on appropriately labeled continuation sheets. CITY STATE ZIP CODE -- S� 1 - � �, _ o (tiGI -`Lp7� ('4 -5'3 3. Verification have used all reasonable diligence in preparing this statement and to the best CANDIDATE, OR STATE MFASURE PROPONENT Executed on By DATE SIGNATURE OF CONTROLLING OFF 10EHOLDER. CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (April/2011) FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772) "Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME -J'it-n f 4. Type of Committee Complete the applicable sections. Controlled Committee STATEMENT OF ORGANIZATION 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. ELECTIVE OFFICE SOUGHT OR HELD NAME OF CAN DIDATE/OFFICEHOLDER /STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY Q O{ 2� I Z Non- Partisan J(� ❑ 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 BANK ACCOUNT NUMBER �n (eDr) 5 -j�3 - 6 o --1- / o lie 3 sy ADDRESS CITY STATE ZIP CODE Primarily Formed Committee 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 FPPC Form 410 (April /2011) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772) Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE - x � (L_ y0-.— -�_LQ/z 4. Type of Committee (Continued) PROVIDE BRIEF DESCRIPTION NAME OF SPONSOR Not formed to support or oppose specific candidates or measures in a single election. Check only one box: ❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee List additional sponsors on an attachment. NO. AND STREE w INDUSTRY GROUP OR AFFILIATION OF SPONSOR STATE ZIP CODE STATEMENT OF ORGANIZATION Page 3 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 (Apri112011) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)