410 Soubirous (02-14-13) Amendment R

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Statement 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: # IS5Ss8( J1 13 Date qualified as committee (If applicable) Mike Soubirous for Riverside City Council - Ward 3, 2013 Date Stamp ❑ Termination — See Part 5 RFCEIVED List I.D. number: STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE /PHONE Riverside CA MAILING ADDRESS (IF DIFFERENT) OPTIONAL: FAX/ E -MAIL ADDRESS COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE Riverside Attach additional information on appropriately labeled continuation sheets_ Date of Termination FEB 14 2013 :ity of Riverside ity Clerk's Office 2. Treasurer and Other Principal Officers NAME OF TREASURER Ms. Dana Hopkins, CPA STREET ADDRESS STATEMENT OF ORGANIZATION For Official Use CITY STATE ZIP CODE AREA CODE/PHONE Riverside CA NAME OF ASSISTANT TREASURER, IF ANY STREET ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NAME AND POSITION OF OTHER PRINCIPALOFFICER(S), IF APPLICABLE MAILING ADDRESS CITY STATE ZIP CODE AREA CODE /PHONE 3. Verification I have used all reasonable diligence in preparing this statement and to th is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true Executed on - ( 1 _ 2 i 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 FPPC Form 410 (January/05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772)