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Statement of Organization <br />Recipient Committee <br />INSTRUCTIONS ON REVERSE <br />Page Z <br />COMMITTEE NAME •� �� +, I.D. NUMBER <br />• All committees must list the financial institution where the campaign bank account is located. <br />NAME OF FINANCIAL INSTITUTION <br />1 <br />BANK ACCOUNT NUMBER <br />ADDRESS CITY STATE ZIP CODE <br />• 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 <br />district number, if any, and the year of the election. <br />• List the political party with which each officeholder or candidate is affiliated or check "nonpartisan." <br />• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. <br />ELECTIVE OFFICE SOUGHT OR HELD <br />NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY <br />Nonpartisan <br />❑ Nonpartisan <br />Primarily formed to support or oppose specific candidates or measures in a single election. List below: <br />CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT N0. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION <br />(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE <br />- <br />SUPPORT <br />OPPOSE <br />_ <br />- <br />- SUPPORT <br />OPPOSE <br />El <br />FPPC Form 410 (Jan /2016) <br />FPPC Advice: advice@fppc.ca.gov (866/275 -3772) <br />www.fppc.ca.gov <br />