Statement of Organization Recipient Committee
410
CALIFORNIA FORM
Date Stamp
Statement Type
Initial Not yet qualified or Date qualification threshold met
Amendment
Termination – See Part 5
For Official use Only
✔
A
Date of termination
Date qualification threshold met
●
09 04 20XX
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1. Committee Information I.D. Number (if applicable)
2. Treasurer and Other Principal Officers
nAMe OF TReASuReR
nAMe OF COMMITTee
Manuel Alvarez for Mayor 20XX
STReeT ADDReSS (nO P.O. BOx) Madeline Richards 225 Presley Street
CITy
STATe CA
zIP CODe
AReA CODe/PHOne
STReeT ADDReSS (nO P.O. BOx)
95443
225 Presley Street
Oakmont
(707)555-6868
nAMe OF ASSISTAnT TReASuReR, IF Any
CITy
STATe
zIP CODe
AReA CODe/PHOne
STReeT ADDReSS (nO P.O. BOx) Manuel Alvarez 225 Presley Street
Oakmont
CA 95443
(707)555-6868
Full MAIlIng ADDReSS (IF DIFFeRenT)
P.O. Box 1744, Oakmont, CA 95434
CITy
STATe
zIP CODe
AReA CODe/PHOne
e-MAIl ADDReSS (RequIReD) / FAx (OPTIOnAl)
(707)555-6868
Oakmont
CA 95443
707-555-6869 / mrichards@oakmontmail.com
COunTy OF DOMICIle
JuRISDICTIOn WHeRe COMMITTee IS ACTIve
nAMe OF PRInCIPAl OFFICeR(S)
SanMarino
Oakmont
N/A
STReeT ADDReSS (nO P.O. BOx)
CITy
STATe
zIP CODe
AReA CODe/PHOne
Attach additional information on appropriately labeled continuation sheets.
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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
DATe [Date Required] [Date Required]
By
SIgnATuRe OF TReASuReR OR ASSISTAnT TReASuReR
executed on
By
DATe
SIgnATuRe OF COnTROllIng OFFICeHOlDeR, CAnDIDATe, OR STATe MeASuRe PROPOnenT
executed on
By
DATe
SIgnATuRe OF COnTROllIng OFFICeHOlDeR, CAnDIDATe, OR STATe MeASuRe PROPOnenT
executed on
By
DATe
SIgnATuRe OF COnTROllIng OFFICeHOlDeR, CAnDIDATe, OR STATe MeASuRe PROPOnenT
FPPC Form 410 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov
Clear Page
Fair Political Practices Commission advice@fppc.ca.gov
Chapter 2.28
Campaign Manual 2 August 2023 Page 154
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