410 Skiles CC W3 (05-06-19)Termination_R

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Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE CALIFORNIA 41 0 FORM Page 3 COMMITTEENAME V - yE1 .. ,ry 3 L�Lt �TCc.f ity /1/di 1.0. VUMBER 4. Type of Committee (Continued) Genera! Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box: CITY Committee 0 COUNTY Committee 0 STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY (xr1✓I T7 j� / a '�� 51 x &(-)7-5-1 /4.12Sr2 L I f� Sponsored Committee List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OS AFFILIATION OF SPONSOR STREET ADDRESS NO. AND STREET CITY STATS TIP CODE AREA CQDEIP-iONE Small Contributor Committee ❑ / / Date qualified 5. Termination Requirements ay signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent certify that all of the fallowing conditions have been met: • This committee has ceased to receive contributions and make expenditures; • This committee does not anticipate receiving contributions or making expenditures in the future; • This committee has eliminated or has no intention or ability to discharge all debts, loans received, and other obligations; • This committee has no surplus funds; and • This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions. There are restrictions on the disposition of surplus campaign funds held by elected officers who are leaving office and by defeated candidates. Refer to Government Code Section 89519. -- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511- 89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5. FP PC Fon-11410 (August/2018) FP PC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov