RAY RUSSOM, CAREN - FORM 410 - QUALIFIED *statement of Organization Date Stamp CALIFORNIA
Rcii nt Committee RECEIVED FORM 41 0
'' Statement Type I Initial 0 Amendment 0 Termination–See Part 5 For Official Use Only
'0'1Not yet qualified JUN 2 3.2022
or
®Date qualification threshold met Date qualification threshold met Date of termination CITY CLERK'S OFFICE
— J� Z Z _�_� _�/_� CITY OF ARROYO GRANDE
1. Committee Information I.D. Number 2. Treasurer and Other Principal Officers
(if applicable)
NAME OF COMMITTEE NAME OF TREASURER -
CacrOri ' v J Rt Isom -epic"AA air- 20 22 Caren. Res 5 o rn
STREET ADDRESS(NO P.O.BOX) •
— --
STREET ADDRESS(NO P.O.BOX) CITY STATEZIP CODE AREA CODE/PHONE
- - A-rroup Ge^cc-z cLe . c1 134-Zo -
CITY STATE ZIP CODE , AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY
A rrbu o G'-a.v -e, C4 C e420
FULL MAIUNG 1CCDRESS(IF DIFFERENT) STREET ADDRESS(NO P.O.BOX)
E-MAIL ADDRESS(REQUIRED)/FAX(OPTIONAL) CITY STATE ZIP CODE AREACODE/PHONE
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(S)
'1 L..0 t.c S Obt s po .6c r rad o &2c.YLo� .
c 1 STREET ADDRESS(NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE -
Attach additional information on appropriately labeled continuation sheets.
3. Verification
I have used all reasonable diligence in preparing this state ent and to the best of my know edge t e information contained herein is true and complete. I certify under
penalty of perjury un er the laws of the State of lifo ).gy ` at
SIGNATURE OF TREASURER OR ASSISTANT TREASURER
Executed on 1,21 I 1-1122'
-t1 �� 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(alfppc.ca.eov(866/275-3772)
www.fppc.ce.gov
Statement of Organization CALIFORNIA
Recipient Committee FORM 41
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME
� A I.D.NUMBER
�� R R SS° Ju LQ- V,v 202—
Z
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
C — - 5 C,oc f ?VD - 2 -
ADDRESS CITY STATE ZIP CODE
I 1vg0 We-s* BraLack Arc). o 9.54'w
4. Type of Committee Complete the applicable sections.
Controlled Committee
• 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 district number,if any,and the year of the election.
• List the political party with which each officeholder or candidate is affiliated or check"nonpartisan." Stating"No party preference"is acceptable
• If this committee acts jointly with another controlled committee,list the name and identification number of the other controlled committee.
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD YEAR OF PARTY
(INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION CHECK ONE
Nonpartisan Partisan (list political party below)
Nonpartisan Partisan (list political party below)
Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S)NAME OR MEASURE(S)FULL TITLE(INCLUDE BALLOT NO.OR LETTER) CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION
IF A RECALL,STATE"RECALL"IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO.,CITY OR COUNTY,AS APPLICABLE) CHECK ONE
SUPPORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410(August/2018)
FPPC Advice:advice(a)fppc.ca.gov(866/275.3772)
www.fppc.ca.gov
•
Statement of Organization CALIFORNIA
•"Recipient Committee FORM 410
INSTRUCTIONS ON REVERSE
COMMITTEE NAME Page 3
1.0.NUMBER
'A.Type of Committee (Continued)
eneral Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
0 CITY Committee 0 COUNTY Committee
0 STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee list additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO.AND STREET CITY STATE ZIP CODE AREA CODE/PHONE
Small Contributor Committee 0 -/-�
--- Date qualified
.Termination Requirements By signing the verification,the treasurer,assistant treasurer and/or candidate,officeholder,or ponent certify that all of the following 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.
FPPC Form 410(August/2018)
FPPC Advice:advice(a?fppc.ca.gov(866/275-3772)
www fppc.ca.gov