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Statement of Organization <br />Recipient Committee <br />Statement Type ❑ Initial <br />Not yet qualified ❑ or <br />Date qualified as committee <br />® Amendment <br />List I.D. number: <br />#1355581 <br />02 /07 /2013 <br />Date qualified as committee <br />(If applicable) <br />NAME OF COMMITTEE <br />Re -Elect Mike Soubirous to City Council 2019 <br />i <br />❑ Termination — See Part 5 <br />List I.D. number: <br />Date of Termination <br />Riverside CA _ <br />MAILING ADDRESS (IF DIFFERENT) <br />FAX / E -MAIL ADDRESS <br />COUNTY OF DOMICILE I JURISDICTION WHERE COMMITTEE IS ACTIVE <br />Riverside <br />Attach additional information on appropriately labeled continuation sheets. <br />I have used all reasonable diligence in prepari <br />penalty of perjury under the laws of the S <br />Executed on �' i !� 0 ( U By <br />i DATE <br />Executed on /`� , \ I By <br />DATE <br />Executed on <br />DATE <br />NAME OF TREASURER <br />Date Stamp <br />g <br />City= 6varid <br />City y ;'k's Office <br />Dana Hopkins, CPA <br />STREET ADDRESS (NO P.O. BOX) <br />For Official Use Only <br />STATE ZIP CODE AREA CODE /PHONE <br />Riverside CA <br />NAME OF ASSISTANT TREASURER, IF ANY <br />STREET ADDRESS (NO P.O. BOX) <br />CITY STATE ZIP CODE AREA CODE /PHONE <br />NAME OF PRINCIPAL OFFICER(S) <br />STREET ADDRESS (NO P.O. BOX) <br />CITY STATE ZIP CODE AREA CODE /PHONE <br />ledge the information contained herein is true and complete. I certify under <br />rrect. <br />By <br />SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT <br />Executed on By <br />DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT <br />FPPC Form 410 (Jan /2016) <br />FPPC Advice: advice @fppc.ca.gov (866/275 -3772) <br />www.fppc.ca.gov <br />