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410 Booker CC W1 (09-08-17)_R
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9/15/2017 5:32:52 PM
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Statement of Organization <br />Recipient Committee <br />Statement Type Initial ( / ❑ Amendment <br />Notyetqualified d or 1/ List I.D. number: <br />/�7yg� <br />❑ Termination — See Part 5 <br />List I.D. number: <br />Date qualified as committee Date qualified as committee Date of Termination <br />(If applicable) <br />NAME OF COMMITTEE <br />CODE/PHONE <br />MAILING ADDRESS (IF DIFFERENT) <br />FAX / E -MAIL ADDRESS <br />NAME OF TREASURER <br />Date Stamp <br />CEIVED AND FILE <br />e office of the Secretary of State <br />of the State of California 2017 <br />AUG 2 8 2017 <br />city of Riverside <br />City PwWs Office <br />iET AD RESS (NO . BOX) <br />CI _ STATE Z =P CODE AREA CODE /PHONE <br />NAME OF PRINCIPAL OFFICER(S) <br />STREET ADDRESS (NO P.O. BOX) <br />Attach additional information on a CITY STATE ZIP CODE AREA CODE /PHONE <br />f appropriately labeled continuation sheets. <br />I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and com <br />penalty of perjury under the laws of the State of California t t. <br />Executed on ( a& 1 ` By <br />DATE } R OR ASSISTANT TREASURER <br />Executed on 2i\ k-N By <br />DATE <br />Executed on By <br />DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT <br />Executed on <br />DATE <br />By <br />SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT <br />e_td:: J certify under <br />-1 <br />I <br />`. <br />FPPC Form 410 (Jan /2016) <br />FPPC Advice: advice @fppc.ca.gov (866/275 -3772) <br />www.fppc.ca.gov <br />
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