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Statement of Organization <br />Recipient Committee <br />Statement Type Initial <br />Not yet qualified 0 or <br />❑ Amendment <br />List I.D. number: <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 />1. Committee <br />NAME OF COMMITTEE <br />STREET ADDRESS (NO P.O. BOX) <br />2. <br />Treasurer and Other Principal Officers <br />NAME OF TREASURER <br />For Official Use Only <br />%)4K4 \Q— <br />MAILING ADDRESS (IF DIFFERENT) <br />STREET ADDRESS (NO P.O. a0x) - <br />Attacli addiiional information on appropriately labeled continuation sheets. CITY STATE ZIP CODE AREA CODE /PHONE <br />3. Verification <br />I have used all reasonable diligence in preparing this statement and to the best of m knowledge the information contained herein is true and complete. I certify under <br />penalty of perjury under the laws of the State of California ct, <br />aExecuted on C]��1� `_ .,Y DATE AsuRE OR ASSISTANT TREASURER - <br />Executed on �� By <br />DATE <br />Executed on By <br />DATE 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 />