RAY RUSSOM, CAREN - FORM 410 - AMENDMENT Statement of Organization Date Stamp CALIFORNIA 41 0
Recipient Committee RECEIVED FORM
Statement Type 0 Initial ® Amendment ❑ Termination-See Part 5 For Official Use Only
0 Not yet qualified MAR 0 3 2020
or
0 Date qualification threshold met Date qualification threshold met Date of termination CITY CLERK'S OFFICE
CITY OF ARROYO GRANDE
—_/—,/ _______I_/_ _t_._/_..
I.D. Number .
1. Committee information 1406391 2. Treasurer and"Other Principal.Officers -
! , (if applicable) ' .
NAME OF COMMITTEE NAME OF TREASURER
Caren Ray Russom for Mayor 2020 Caren Ray Russom
STREET ADDRESS(NO P.O.BOX) '
STREET ADDRESS(NO P.O.BOX) CITY STATE ZIP CODE AREA CODE/PHONE
Arroyo Grande CA 93420
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY
Arroyo Grande CA 93420
FULL MAILING ADDRESS(IF DIFFERENT) STREET ADDRESS(NO P.O.BOX)
E-MAIL ADDRESS(REQUIRED)/FAX(OPTIONAL) CITY STATE ZIP CODE AREA CODE/PHONE
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(S)
San Luis Obispo City of Arroyo Grande
STREET ADDRESS(NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
Attach additional information on appropriately labeled continuation sheets.
�3 =Veri 'cation�� -- . . ,..:.. . .�... ,:. 7 .. ,f - - ,--_,'� :
I have used all reasonable diligence in preparin:this tate -nt and to the best of my knowledge the information contained herein is true and complete. I certify under
penalty of perjury nd r the laws of the State .
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
Statement of Organization CALIFORNIA 41 0
Recipient Committee • FORM
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D.NUMBER
Caren Ray Russom for Mayor 2020 1406391
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
Coast Hills Credit Union 805-733-7600
ADDRESS CITY STATE ZIP CODE
1580 West Branch Street Arroyo Grande CA 93420
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.
ELECTIVE OFFICE SOUGHT OR HELD YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (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@fppc.ca.gov(866/275-3772)
www.fppc.ca.gov