HomeMy WebLinkAbout410 01/30/2013 officeholder and Candidate Campaign Statement - Short Form Termination Gordon A ShanksStatement of Organization STATEMENT OF ORGANIZATION
Recipient Committee Type or print in ink Date Stamp
Statement Type ❑ Initial
Not yet qualified ❑ or
❑ Amendment
List I.D. number:
Date qualified as committee Date qualified as committee
(It applicable)
Committee Information
NAME OF COMMITTEE
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List I.D. number: F_(
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AREACODE /PHONE
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MAILING ADDRESS (IF DIFFERENT)
OPTIONAL: FAX/ E- MAILADDRESS
/ t y 1 3
Date of Termination
Attach additional information on appropriately labeled continuation sheets.
2. Treasurer and
NAME OF TREASURER
STREETADDRESS (NO PO. BOX)
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JAN 3 0 213
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Officers
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF ASSISTANT TREASURER, IF ANY
STREETADDRESS (NO PO. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF PRINCIPAL OFFICERS)
STREETADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and complete. I certify under penalty of
perjury under the laws of the State of California that the foregoing is true and correct.
Executed on
/I DATE
/
Executed on R / ri /l
/ / DATE
Executed on
Executed on
DATE
By
SIGNATURE OF TREASURER OR ASSISTANT TREASURER
By
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE ONTR LL N OFFICEHOLDER, A A TAT E MEASURE PROPON N
FPPC Form 410 (April /2011)
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