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Statement of Organization <br />Recipient Committee <br />INSTRUCTIONS ON REVERSE <br />COMMITTEE NAME <br />IL <br />• All committees must list the financial institution where the campaign bank account is located. <br />NAME OF FINANCIAL INSTITUTION <br />ADDRESS <br />)e of Committee Complete the applicable sections. <br />BANK ACCOUNT NUMBER <br />STATE ZIP CODE <br />Page 2 <br />I.D. NUMBER <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 />NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD <br />(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY <br />Nonpartisan <br />I I 1 U Nonpartisan <br />Primorily Formed Committee 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 NO, OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION <br />(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) <br />SUPPORT <br />IVI <br />FPPC Form 410 (Jan/2016) <br />FPPC Advice: advice @fppc.ca.gov (866/275 -3772) <br />www.fppc.ca.gov <br />