Statement of Organization

Recipient Committee
CALIFORNIA
FORM 410
Who Files Where to File Form 410:
Recipient Committees: Persons (including an All Committees: Form 410 with original ink signature(s)
officeholder or candidate), organizations, groups, or Secretary of State • A recipient committee that qualifies during
other entities that raise contributions from others Political Reform Division the 16 days prior to an election in which it
totaling $2,000 or more in a calendar year to spend 1500 11th Street, Rm 495 must file pre-election statements must file
on California elections. They must register with Sacramento, CA 95814 a Form 410 within 24 hours of qualification
the Secretary of State and report all receipts and with the filing officer who will receive the
expenditures. “Contributions” include monetary County & City committee’s original disclosure statements.
payments, loans and non-monetary goods and Committees: Also file a copy with the
local filing officer who will receive • A recipient committee that qualifies during the
services received or made for a political purpose. 90 days prior to an election or on the date of
the original campaign statements.
Candidates: The personal funds of a candidate or the election in which the committee makes
officeholder used to seek or hold elective office Read instructions carefully as a Form 410 will be independent expenditures of $1,000 or more to
are contributions and count toward qualifying as rejected if all applicable sections are not completed. support or oppose a candidate in that election must
a recipient committee. However, personal funds file the Form 410 within 24 hours of qualification
Committee ID Number with the filing officer who will receive the
used to pay a candidate filing fee or a fee for the
The committee’s ID number will be posted at cal-access. committee’s original disclosure statements and with
statement of qualifications to appear in the ballot
sos.ca.gov. To receive an official, stamped copy of the filing officer(s) for the candidate(s) supported
pamphlet do not count toward the $2,000 threshold.
your approved Form 410, send a request, the original or opposed by the independent expenditure.
Multipurpose Organizations: A nonprofit form, two copies of the form, and a self-addressed,
organization, federal or out-of-state PAC, or other stamped envelope, to the Secretary of State. • If, during the 16 days prior to an election when
multipurpose organization that makes contributions a committee is required to file pre-election
Amendments statements, a change occurs in the name of
or expenditures in California elections may also
When information contained in the committee’s the committee, the treasurer or other principal
be required to register as a recipient committee
Statement of Organization changes, file an amendment officers, or the controlling candidate, an
with the Secretary of State. See the Fact Sheet on
within 10 days of the change with the Secretary of amendment must be filed with the filing officer
Multipurpose Organizations Reporting Political
State and local filing officer (if applicable). During receiving the committee’s original campaign
Spending and the Supplemental Form 410 Instructions.
the period 16 days before an election, file an statements within 24 hours of the change.
When to File amendment within 24 hours as described below.
File this form within 10 days of receiving $2,000 These filings must be made by fax, guaranteed
24-Hour Reporting overnight delivery, personal delivery or
in contributions. Include a $50 payment made
In addition to the 10-day rule to file an original online (if online filing is available).
payable to the Secretary of State. Thereafter,
the $50 fee is due annually no later than January
15. In addition to the $50 fee, a penalty of
$150 may be assessed if payment is late. This form was prepared by the Fair Political Practices
Commission (FPPC). For detailed information on
For early submissions, mark the “not yet qualified” campaign reporting requirements and the Information
box. The $50 fee is requested at this time but Practices Act of 1977, see the FPPC Campaign
is not legally required until the committee Disclosure Manual for your type of committee.
qualification threshold has been met.
FPPC Form 410 (August/2018)
FPPC Advice: [email protected] (866/275-3772)
www.fppc.ca.gov
Statement of Organization CALIFORNIA
410
Date Stamp

Recipient Committee FORM

Statement Type Initial Amendment Termination – See Part 5 For Official Use Only

Not yet qualified

or
Date qualification threshold met Date qualification threshold met Date of termination

/ / / / / /
1. Committee Information I.D. Number 2. Treasurer and Other Principal Officers
(if applicable)
NAME OF COMMITTEE NAME OF TREASURER

STREET ADDRESS (NO P.O. BOX)

STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE

CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY

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)

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 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 By
DATE 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: [email protected] (866/275-3772)
www.fppc.ca.gov
Instructions for
Statement of Organization
CALIFORNIA
FORM 410
Statement Type: Identify the jurisdiction where the committee is active. Primarily Formed Committees
Initial For example a city committee lists the name of the city.
Mark the “Initial” box and enter the date the Ballot Measures: The name of each
committee qualification threshold was met. Committee Name Requirements committee primarily formed to support or
oppose a ballot measure must include:
If the committee has not met the qualification threshold, The following committee name rules apply to the Form
mark the “Initial” and “Not Yet Qualified” boxes. 410, the committee’s campaign statements and to any • A statement identifying the ballot measure(s)
other references to the committee required by law. See number or letter and whether it supports
Qualification Threshold the instructions for Part 4 for committee definitions.
or opposes the measure(s) (e.g., Committee
The “date qualification threshold met” is the date
the committee received contributions totaling Candidate Controlled Committees: Any committee that For Proposition/Measure __ or Committee
$2,000 or more during a calendar year. is controlled by a state or local candidate or officeholder Against Proposition/Measure __).
must include the last name of the candidate in the name
Amendment of the committee. In addition, the following rules apply: Recalls: Each committee established for a recall
If any of the information reported on an initial election must include the name of the officeholder
statement of organization changes: • An election committee controlled by one or subject to the recall. If the committee is not
more state or local candidates must also include controlled by the officeholder, the committee must
• Mark the amendment box; the office the candidate(s) is seeking and the state its support or opposition (e.g., Committee
• Include the committee’s ID number and name; year of the election (e.g., Friends of Smith for Opposing the Recall of Council Member Doe).
Assembly 20XX, Jones for Council 20XX).
• Provide the changed information; and Supporting or Opposing a Candidate: The name of
• An officeholder committee set up by a state each committee primarily formed to support or oppose
• Complete the verification. a state or local candidate(s) being voted on in a single
officeholder must also include the office held, the
Candidates: Under certain circumstances, a candidate year the officeholder was elected to the current election, other than a recall election, must include
for local office may amend the Form 410 to indicate term of office, and the words “Officeholder the last name of each candidate, the office sought,
that he or she is seeking re-election to the same office. Account,” as part of the committee name (e.g., the year of the election and must state whether the
A candidate for state office must open a separate Anderson Assembly 20XX Officeholder Account). committee supports or opposes the candidate(s)
committee for each term of office and may not amend (e.g., Committee to Support Doe for Senate 20XX).
• A legal defense fund set up by a state or local
the Form 410 to redesignate an election committee.
candidate or officeholder must also include the
Termination words “Legal Defense Fund” as part of the committee
List the committee’s name, identification name (e.g., Senator Smith Legal Defense Fund).
number and indicate the date of termination,
• A ballot measure committee controlled by one
including completing the verification.
or more state candidates must also state that it is
1. Committee Information: a ballot measure committee (e.g., Senator Lee’s
Provide the full name of the committee. A Ballot Measure Committee) prior to the designation
committee may use only one name. of the ballot measure number. See additional
requirements for primarily formed committees.
The committee’s street address, email address, and
telephone number must be reported. A post office box
is not acceptable. The committee’s mailing address Sponsored Committees: A sponsored committee
must also be reported if it is different from the street (including most political action committees) must include
address. A post office box is acceptable for the mailing the full name of its sponsor in the name of the committee.
address. A committee’s “domicile” is its address as If the committee has more than one sponsor and the
listed on the Form 410. Los Angeles is the county of sponsors are members of an industry or other identifiable FPPC Form 410 (August/2018)
domicile for committees located outside California. group, include a term identifying that industry or group. FPPC Advice: [email protected] (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
CALIFORNIA
FORM 410
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D. NUMBER

• All committees must list the financial institution where the campaign bank account is located.

NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER

ADDRESS CITY STATE ZIP CODE

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: [email protected] (866/275-3772)
www.fppc.ca.gov
Instructions for
Statement of Organization
CALIFORNIA
FORM 410
2. Treasurer and Other Principal Officers: 4. Type of Committee: Primarily Formed Committee
A committee may have only one treasurer and A committee is “primarily formed” when it makes or
one assistant treasurer. A candidate may be his Controlled Committee initially plans to make more than 70% of its contributions
or her own treasurer or assistant treasurer. A and expenditures to support or oppose a specific
committee may not accept a contribution or A “controlled committee” is one which is controlled
candidate or measure, or a group of measures or specific
make an expenditure without a treasurer. directly or indirectly by an officeholder, candidate,
local candidates all being voted upon in the same
or state measure proponent, or which acts jointly
A committee that is not controlled by a candidate or election on the same date. (FPPC Regulation 18247.5)
with an officeholder, candidate, state measure
officeholder must disclose the name, street address, proponent, or another controlled committee New committees: A new committee formed within
and telephone number of the committee’s principal in connection with making expenditures.
officer(s). The principal officer(s) of a committee are six months of a statewide regular election or within
the individual(s) primarily responsible for approving the 30 days of a state special election is presumed to be
A committee is controlled if the officeholder,
political activity of the committee, including authorizing primarily formed if the committee makes at least
candidate, or proponent, his/her agent, or any other
the content of communications, authorizing contributions $25,000 in independent expenditures to support or
committee he/she controls, has a significant influence
and other expenditures, and determining strategy. If oppose a state candidate or measure. Monthly review
on the actions or decisions of the committee.
more than three individuals qualify as principal officers is required for other new committees that spend at
of the committee, identify no fewer than three. “Proponents” of state measures are persons who least $1,000 a month and were formed within six
request the Attorney General to prepare a title and months of an election in connection with which the
If no individual other than the committee treasurer
qualifies as a principal officer, identify that summary of a state initiative, referendum, or measure. committee makes contributions or expenditures.
individual as both the treasurer and the principal
Candidate Election Committee: Identify Quarterly review at the end of March, June, September
officer. An attachment may be necessary.
the candidate’s last name, office, election and December is required for other committees.
3. Verification/Original Ink Signature(s): year and party, if applicable.
A committee controlled by a candidate for his or her
The Form 410 filed with the Secretary of State must
Ballot Measure Committee Controlled by State own candidacy is not a primarily formed committee.
contain an original signature(s). The committee treasurer
Candidate: Identify each measure on which the
or assistant treasurer must sign the Form 410. Also, committee has spent or anticipates spending $50,000 State ballot measures - qualification ID number: Certain
each controlling officeholder, candidate or state ballot or more in the current two-year period, beginning committees must list in Section 4, Primarily Formed
measure proponent must sign the Form 410. If more with January 1 of an odd-numbered year. If the Committee, the Attorney General’s Office assigned
than three control the committee, one of them may sign ballot designation has not been assigned, describe identification number to a proposed state ballot measure:
on behalf of all controlling individuals. If a candidate the purpose of the anticipated measure(s). Amend
will serve as his or her own treasurer, he or she must • A committee submitting the title and summary;
the Form 410 when a ballot designation is assigned.
sign as the candidate and again as the treasurer. Provide this information in the primarily formed or • A committee primarily formed for the measure; or
general purpose section or on an attachment.
Bank Account Information • A
committee that spends $100,000 or more
Legal Defense Committee: On an attachment, on petition circulation for the measure.
• Qualified committees must list the name and address
describe the specific legal dispute(s) for which the
of the financial institution where the campaign bank Recall Committees: A committee supporting or opposing
legal defense fund was established. The Form 410
account is located and the bank account number. a recall must list “Recall [Officeholder’s Name],” the
must be amended within 10 days when legal disputes
• Non-qualified committees are not are either resolved or new disputes are initiated. office held by the recall target officeholder, and mark
required to list a bank account. the appropriate box to indicate whether the committee
supports or opposes the recall of the officeholder.
FPPC Form 410 (August/2018)
FPPC Advice: [email protected] (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
CALIFORNIA
FORM 410
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D. NUMBER

4. Type of Committee (Continued)

General Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
CITY Committee COUNTY Committee 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 / /

Date qualified

5. 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: [email protected] (866/275-3772)
www.fppc.ca.gov
Instructions for
Statement of Organization
CALIFORNIA
FORM 410
General Purpose Committee jurisdictional status each month the committee makes receives contributions from 100 or more
A committee is a “general purpose committee” expenditures of $1,000 or more. If a change of filing persons; makes contributions to five or more
if its principal activity is supporting or opposing locations occurs, reports must be filed in both the candidates; and has not received more than
a variety of candidates or measures voted on in new and old jurisdiction through the calendar year. $200 from one person in a calendar year.
different elections. (FPPC Regulation 18227.5)
After marking the appropriate state, county or city box, 5. Termination Requirements
• A state committee makes contributions or provide a brief description of the committee’s political
expenditures to support or oppose candidates or activities such as whether it supports candidates or Recipient committees may only terminate when:
measures voted on in state elections, or in more measures that share a common political affiliation.
than one county; it does not make over 70% of • They have ceased to receive contributions
its contributions or expenditures in a single local and make expenditures; and
Sponsored Committee
jurisdiction. State contributions include contributions • They do not anticipate receiving contributions,
to other state general purpose committees. All A “sponsored committee” is a general purpose repayments of outstanding loans made to others,
political party committees that meet the requirements or primarily formed committee, other than or any other receipts in the future, and they do not
as a political party pursuant to Elections Code Section an officeholder or candidate controlled anticipate making expenditures in the future; and
5100 (Government Code Section 85205) (including committee, that has one or more sponsors.
county central committees) are state committees. • They have eliminated or have no intention
An organization, business, or other entity is a or ability to discharge all their debts, loans
• A county committee makes more than 70% of received, and other obligations; and
sponsor if one or more of the following apply:
its contributions or expenditures to support or
oppose candidates or measures voted on in a single • The committee receives 80% or more of its • They have no funds; and
county, or in more than one jurisdiction within contributions from the entity or organization or its
one county. This includes contributions to other members, officers, employees, or shareholders. • They have filed all required campaign
general purpose committees in the same county. statements disclosing all reportable
• The entity or organization collects contributions transactions, including disposition of funds.
• A city committee makes more than 70% of its for the committee by use of payroll deductions or
contributions or expenditures to support or dues from its members, officers or employees. State Candidates: There are mandatory termination
oppose candidates or measures voted on in deadlines applicable to your committees.
a single city, or in one consolidated city and • The entity or organization, alone or
county. This includes contributions to other city in combination with other entities or How to Terminate
general purpose committees in the same city. organizations, provides all or nearly all of the After the termination requirements above are met:
administrative services for the committee.
A city or county committee may make up to four State Committees: Complete page one of the
contributions in a calendar year to candidates • The entity or organization, alone or in combination Form 410 and mark the termination box. Send
for elective state office whose districts are with other entities or organizations, sets the the Form and last Form 450 or 460 (mark the
within the same jurisdiction and is not required policies for contribution solicitations or payment
termination box) to the Secretary of State.
to change its status to a state committee. of expenditures from committee funds.
Local Committees: Complete page one of the
A committee that has made contributions or expenditures See the instructions for Part 1 for a sponsored
Form 410, mark the termination box and send the
of $5,000 or more during a quarter must review its committee’s name requirements.
Form to the Secretary of State. Send a copy of
activity at the end of March, June, September and Small Contributor Committee the Form 410 and last Form 450 or 460 (mark the
December to determine if the committee is filing termination box) to your city or county filing officer.
reports in the appropriate jurisdiction. During the A “small contributor committee” is one that has
first six months, a new committee must check its been in existence for more than six months; FPPC Form 410 (August/2018)
FPPC Advice: [email protected] (866/275-3772)
www.fppc.ca.gov