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Statement of Organization <br />Recipient Committee <br />INSTRUCTIONS ON REVERSE <br />• All committees must list the financial institution where the campaign bank account is located. <br />NAME OF FINANCIAL INSTITUTION <br />ADDRESS <br />a. l+/pe 43T (.ommgtee Complete the applicable sections. <br />Controiied-Committee <br />AREA CODEX' <br />CITY <br />&ve(csi <br />ONE <br />BANK ACCOUNT NUMBER <br />STAYS <br />c'. <br />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." Stating "No party preference" is acceptable. <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 <br />ELECTIVE OFFICE SOUGHT OR HELD <br />(INCLUDE DISTRICT NUMBER IF APPLICABLE) <br />YEAR OF <br />ELECTION <br />'TM <br />ECK ONE <br />�7vi Q �� �n <br />�nc <br />i [ le 4✓ V1)arJ 5 <br />&o19 <br />Nonpar n <br />Partisan <br />❑ <br />(list political party below) <br />f l <br />OPPOS1 <br />Nonpartisan <br />n <br />Partisan <br />❑ <br />(list political party below) <br />Primarily Formed Committee <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 NO. OR LETTER) <br />IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. <br />CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURES) JURISDICTION <br />CHECK ONE <br />SUPPORT <br />n <br />OPPOSE <br />n <br />SUPPORT <br />OPPOS1 <br />FPPC Form 410 (August/2018) <br />FPPC Advice: advice@fppc.ca.gov (866/275-3772) <br />www.fppc.ca.gov <br />