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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: RECE, '?� MAR 7 i; City of Rive, . ❑ u`fec�'nination5ee List I.D. number: # I S5S5-S 1 —. # —J 13 Date qualified as committee Date of Termination D E (If applicable)�� Mike Soubirous for Riverside City Council - Ward 3, 2013 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 Riverside COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE Attach additional information on appropriately labeled continuation sheets. Date Stamp Caine o �Ca! Olaf State B 2 0 2013 � A 130WEN 2. Treasurer and Other Pr'incipa fficers NAML OF TREASURER Ms. Dana Hopkins, CPA STATEMENT OF ORGANIZATION a 13 ,,r J al U 7'i O i : I ) COUNITY OF RIVERSIDE SIKttI ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE Riverside CA NAME OFASSISTANT TREASURER, IF ANY STREET ADDRESS CITY STATE ZIP CODE AREA CODE /PHONE NAMEAND POSITION OF OTHER PRINCIPAL OFFICER(S), IFAPPLICABLE MAILING ADDRESS CITY STATE ZIP CODE AREA CODE /PHONE 3. Verification I have used all reasonable diligence in preparing this statement and to the s true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true a Executed on - l l —a 0 13 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)