Laserfiche WebLink
Recipient Committee <br />Campaign Statement <br />Cover Page <br />SEE INSTRUCTIONS ON REVERSE <br />COVER PAGE <br />CALIFORNIA 460 <br />FORM V <br />Statement covers period <br />Date of election if applicable: <br />(Month, Day, Year) <br />1. Type of Recipient Committee: All Commlttees - Complete Parts 1, 2, 3, and 4. <br />CZ Officeholder, Candidate Controlled Committee <br />O State Candidate Election Committee <br />O Recall <br />Also Complete Part 5) <br />❑ General Purpose Committee <br />O Sponsored <br />O Small Contributor Committee <br />O Political Party/Central Committee <br />❑ Primarily Formed Ballot Measure <br />Committee <br />O Controlled <br />O Sponsored <br />(Also Complete Pad 6) <br />❑ Primarily Formed Candidate/ <br />Officeholder Committee <br />(Also Complete Pad 7) <br />2. Type of Statement: <br />❑ Preelection Statement <br />g Semi-annual Statement <br />O Termination Statement <br />(Also file a Form 410 Termination) <br />O Amendment (Explain below) <br />❑ Quarterly Statement <br />❑ Special Odd -Year Report <br />3. Committee Information i I.D. NUMBER <br />it -10 11:3 0 <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) <br />5e e►n M,1 k c v exssick Cot) CA <br />STREET AODRESS (NO P.O. BOX) <br />R.vcs► <br />CITY <br />STATE <br />ZIP CODE AREA CODE/PHONE <br />MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX <br />CITY <br />STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: FAX / E-MAIL ADDRESS <br />Treasurer(s) cQOLn <br />NAME OF TREASURER <br />MAILING ADDRESS <br />CITY <br />"ra_nr,m: 1 <br />NAME OF ASSISTANT TREASURER, IF ANY <br />C01/4. <br />STATE ZIP CODE <br />AREA CODE/PHONE <br />MAILING ADDRESS <br />via. XS <br />CcA <br />CITY <br />STATE ZIP CODE <br />AREA CODE/PHONE <br />OPTIONAL: FAX / E-MAIL ADDRESS <br />4. Verification <br />I have used all reasonable diligence in preparing and reviewing this statement and to the best of m know) h ' d herein and in the attached schedules is true and complete. I <br />certify under penalty of perjury under the laws of the State of California that the foregoing is <br />Executed on <br />Executed on <br />Executed on <br />Executed on <br />Date <br />-l(3�i9 <br />Date <br />7 /axise <br />Date <br />Date <br />By nt Treasurer <br />By <br />Signat Proponent or Responsible Officer of Sponsor <br />Signature of Controlling Officeholder, Candidate, State Measure Proponent <br />By <br />By <br />Signature of Controlling Officeholder Candidate, State Measure Proponent <br />FPPC Form 460 (Jan/2016) <br />FPPC Advice: advice@fppc.ca.gov (866/275-3772) <br />