Fppc Form 410 – Fill Out and Use This PDF

Statement of Organization Recipient Committee

CALIFORNIAFORM 410

When to File

File this form within 10 days of receiving $1,000 in contribuions. Include a $50 payment made payable to the Secretary of State. Thereater, the $50 fee is due annually no later than January 15. In addiion to the $50 fee, a penalty of $150 may be assessed if payment is late.

For early submissions, mark the “not yet qualiied” box. The $50 fee is requested at this ime but is not legally required unil the group qualiies as a commitee.

The commitee’s FPPC ID number will be posted at www.sos.ca.gov. Read instrucions carefully as a Form 410 will be rejected if all applicable secions are not completed. All commitees must now disclose the inancial insituion and bank account number used by the commitee.

Where to File

All Commitees: Original

Secretary of State

Poliical Reform Division

1500 11th Street, Rm 495

Sacramento, CA 95814

County & City

Commitees: Also ile a copy with

local iling oicer who will receive the original campaign statements

Amendments

When informaion contained in the commitee’s Statement of Organizaion changes, ile an amendment

within 10 days of the change with the Secretary of

State and local iling oicer (if applicable). During the period 16 days before an elecion, ile an amendment within 24 hours as described below.

24-Hour Reporing

In addiion to the 10 day rule to ile an original

Form 410:

•a recipient commitee that qualiies during the 16 days prior to an elecion in which it must ile pre- elecion statements must ile a Form 410 within

24 hours of qualiicaion with the iling oicer who will receive the commitee’s original disclosure statements.

•a recipient commitee that qualiies during the

90 days prior to an elecion in which the commitee makes independent expenditures of $1,000 or more to support or oppose a candidate in that elecion must ile the Form 410 within 24 hours of qualiicaion with the iling oicer who will receive the commitee’s original disclosure statements and with the iling oicer(s) for the candidate(s) supported or opposed by the independent expenditure.

•if, during the 16 days prior to an elecion when a commitee is required to ile pre-elecion

statements, a change occurs in the name of the commitee, the treasurer or other principal oicers,

or the controlling candidate, an amendment must be iled with the iling oicer receiving the commitee’s original campaign statements within 24 hours of the change.

These ilings must be made by fax, guaranteed overnight delivery, personal delivery or online (if online iling is available.)

Who Files: Recipient Commitees

Persons (including an oiceholder or candidate), organizaions, groups, or other eniies that raise contribuions from others totaling $1,000 or more in a calendar year to spend on California elecions qualify as a recipient commitee. They must register with the Secretary of State and report all receipts and expenditures. “Contribuions” include monetary payments, loans and non-monetary goods and services received or made for a poliical purpose.

Exising nonproit organizaions, federal and out-of- state PACs, and other mulipurpose organizaions that receive contribuions from others and make occasional expenditures in California elecions must also register as a recipient commitee with the Secretary of State. They must report the amount of their expenditures on California candidates or ballot measures and disclose the sources of those funds. (FPPC Reg. 18215.)

Candidates: The personal funds of a candidate or oiceholder used to seek or hold elecive oice are contribuions and count toward qualifying as a recipient commitee. However, personal funds used to pay a candidate iling fee or a fee for the statement of qualiicaions to appear in the ballot pamphlet do not count toward the $1,000 threshold.

This form was prepared by the Fair Poliical Pracices Commission (FPPC). For detailed informaion on campaign reporing requirements and the Informaion Pracices Act of 1977, see the FPPC Campaign Disclosure Manual.

FPPC Form 410 (Dec/2012) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov

Statement of Organization Recipient Committee

Statement Type	Initial
	Not yet qualiied

OR

Amendment

List I.D. number:

#

Date Stamp

Terminaion – See Part 5

List I.D. number:

#

CALIFORNIAFORM 410

For Oicial Use Only

	/		/				/		/
Date qualiied as committee						Date qualiied as commitee
								(If applicable)

1. Commitee Informaion

/ /

Date of Terminaion

2. Treasurer and Other Principal Oicers

STREET ADDRESS (NO P.O. BOX)

CITY

STATE

ZIP CODE

AREA CODE/PHONE

MAILING ADDRESS (IF DIFFERENT)

FAX / E-MAIL ADDRESS

COUNTY OF DOMICILE	JURISDICTION WHERE COMMITTEE IS ACTIVE

Atach addiional informaion on appropriately labeled coninuaion sheets.

STREET ADDRESS (NO P.O. BOX)

CITY

STATE

ZIP CODE

AREA CODE/PHONE

NAME OF ASSISTANT TREASURER, IF ANY

STREET ADDRESS (NO P.O. BOX)

CITY

STATE

ZIP CODE

AREA CODE/PHONE

NAME OF PRINCIPAL OFFICER(S)

STREET ADDRESS (NO P.O. BOX)

Executed on

DATE

Executed on

DATE

Executed on

DATE

Executed on

DATE

By

SIGNATURE OF TREASURER OR ASSISTANT TREASURER

By

SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT

By

SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT

By

SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT

Instructions for Statement of Organization

CALIFORNIAFORM 410

Statement Type:

Iniial

The “date qualiied” as a commitee is the date that the commitee received contribuions totaling $1,000 or more during a calendar year.

Amendment

If any of the informaion reported on an iniial statement of organizaion changes:

•Mark the amendment box;

•Include the commitee’s ID number and name;

•Provide the changed informaion; and

•Complete the veriicaion.

Candidates:

Under certain circumstances, a candidate for local oice

may amend the Form 410 to indicate that he or she is seeking another term of the same oice (re-elecion). A candidate for state oice must open a separate commitee for each term of oice and may not amend the Form 410 to redesignate an elecion commitee.

Terminaion

List the commitee’s ideniicaion number and indicate the date of terminaion.

1. Commitee Informaion:

Provide the full name of the commitee. A commitee may use only one name.

The commitee’s street address must be reported. A post oice box is not acceptable. The commitee’s mailing address must also be reported if it is diferent from the commitee’s street address. A post oice box is acceptable for the mailing address. A commitee’s “domicile” is its address as listed on the Form 410. Los Angeles is the county of domicile for commitees located outside California.

Idenify the jurisdicion where the commitee is acive. For example a city commitee lists the name of the city.

Commitee Name Requirements

The following commitee name rules apply to the Form 410, the commitee’s campaign statements and to any other references to the commitee required by law. See the instrucions for Part 4 for commitee deiniions.

Candidate Controlled Commitees (including ballot measure commitees): Any commitee that is controlled by a state or local candidate or oiceholder

must include the last name of the candidate in the name of the commitee. In addiion, the following rules also apply:

•An elecion commitee controlled by one or more

state or local candidates must also include the oice the candidate(s) is seeking and the year of the elecion (e.g., Friends of Smith for Assembly 20XX, Jones for Council 20XX).

•An oiceholder commitee set up by a state oiceholder must also include the oice held, the year the oiceholder was elected to the current term of oice, and the words “Oiceholder Account,”

as part of the commitee name (e.g., Anderson Assembly 20XX Oiceholder Account).

•A legal defense fund set up by a state or local candidate or oiceholder must also include the words “Legal Defense Fund” as part of the commitee name (e.g., Senator Smith Legal Defense Fund).

•A ballot measure commitee controlled by one or

more state candidates must also state that it is a ballot measure commitee (e.g., Senator Lee’s Ballot Measure Commitee). See addiional requirements for primarily formed commitees.

Sponsored Commitees: A sponsored commitee (including most poliical acion commitees) must include the full name of its sponsor in the name of the commitee. If the commitee has more than one sponsor and the sponsors are members of an industry or other ideniiable group, include a term idenifying that industry or group.

Primarily Formed Commitees

Ballot Measures: The name of each commitee primarily formed to support or oppose a ballot measure

must include:

•A statement idenifying the ballot measure(s) number or leter and whether it supports or opposes the measure(s) (e.g., Commitee For Proposiion/ Measure __ or Commitee Against Proposiion/ Measure __).

•The name must include the economic or other special interests of its major donors of $50,000

or more, in descending order based on the amount contributed to the commitee. The list of these economic or special interests may not be interspersed with consituencies such as “concerned ciizens, or consumers.”

•The name of any state or local candidate that contributes $50,000 or more.

•Prior to the designaion of the ballot measure number, a primarily formed ballot measure commitee controlled by a state candidate must also state that it is a ballot measure commitee (e.g., Senator Gomez’s Ballot Measure Commitee).

Recalls: Each commitee established for a recall elecion must include the name of the oiceholder subject to the recall. If the commitee is not controlled by the oiceholder, the commitee must state its support or opposiion (e.g., Commitee Opposing the Recall of Council Member Doe).

Supporing or Opposing a Candidate: The name of each commitee primarily formed to support or oppose a state or local candidate(s) being voted on in a single elecion, other than a recall elecion, must include the name of each candidate, the oice sought, the year of the elecion and must state whether the commitee supports or opposes the candidate(s) (e.g., Commitee to Support Doe for Senate 20XX).

Statement of Organization Recipient Committee

INSTRUCTIONS ON REVERSE

COMMITTEE NAME

CALIFORNIAFORM 410

Page 2

I.D. NUMBER

NAME OF FINANCIAL INSTITUTION

AREA CODE/PHONE

BANK ACCOUNT NUMBER

Primarily Formed Commitee

Primarily formed to support or oppose speciic candidates or measures in a single elecion. List below:

SUPPORT

OPPOSE

SUPPORT

OPPOSE

Instructions for Statement of Organization

CALIFORNIAFORM 410

2. Treasurer and Other Principal Oicers:

The commitee may have only one treasurer and one assistant treasurer. A candidate may be his or her own treasurer or assistant treasurer. A commitee may not accept a contribuion or make an expenditure without a treasurer.

A commitee that is not controlled by a candidate or oiceholder must disclose the name, street address, and telephone number of the commitee’s principal oicer(s). The principal oicer(s) of a commitee are the individual(s) primarily responsible for approving the poliical acivity of the commitee, including authorizing the content of commitee communicaions, authorizing the commitee’s contribuions and other expenditures, and determining the commitee’s campaign strategy. If more than three individuals qualify as principal oicers of the commitee, idenify no fewer than three. If no individual other than the commitee treasurer qualiies as a principal oicer, idenify that individual as both the treasurer and the principal oicer. An atachment may be necessary.

3. Veriicaion:

The commitee treasurer or assistant treasurer must sign the Form 410. Also, each controlling oiceholder, candidate or state ballot measure proponent must sign the Form 410. If more than three control the commitee, one of them may sign on behalf of all controlling individuals. If a candidate will serve as

his or her own treasurer, he or she must sign as the candidate and again as the treasurer.

New Requirements

•List the name and address of the inancial insituion where the campaign bank account is located and the bank account number.

If a commitee has more than one bank account, only one account must be listed.

If a campaign bank account is not open at the ime of iling an iniial Form 410, amend the Form 410 within 10 days of opening the bank account.

•State Ballot Measures: Qualiicaion ID number

Certain commitees must list in Secion 4, Primarily Formed Commitee, the Atorney General’s Oice assigned ideniicaion number to a proposed state ballot measure:

•A commitee submiing the itle and summary;

•A commitee primarily formed for the measure; or

•A commitee that spends $100,000 or more on peiion circulaion for the measure.

4.Type of Commitee: Controlled Commitee

A “controlled commitee” is one which is controlled directly or indirectly by an oiceholder, candidate, or state measure proponent, or which acts jointly with an oiceholder, candidate, state measure proponent, or another controlled commitee in connecion with making expenditures.

A commitee is controlled if the oiceholder, candidate, or proponent, his/her agent, or any other commitee he/she controls, has a signiicant inluence on the acions or decisions of the commitee.

“Proponents” of state measures are persons who request the Atorney General to prepare a itle and summary of a state iniiaive, referendum, or measure.

•Candidate Election Committee: Identify the candidate’s name, oice, elecion year and party, if applicable.

•Ballot Measure Commitee Controlled by State

Candidate: Idenify each measure on which the commitee has spent or anicipates spending $50,000 or more in the current two-year period, beginning with January 1 of an odd-numbered year. If the ballot designaion has not been assigned, describe the purpose of the anicipated measure(s). Amend the Form 410 when a ballot designaion is assigned. Provide this informaion in the primarily formed or general purpose secion or on an atachment.

•Legal Defense Commitee: On an atachment, describe the speciic legal dispute or disputes for which the legal defense fund was established. The

Form 410 must be amended within 10 days when legal disputes are either resolved or new disputes are iniiated.

Primarily Formed Commitee

A commitee is “primarily formed” when it makes or iniially plans to make more than 70% of its contribuions and expenditures to support or oppose a speciic candidate or measure, or a group of measures or speciic local candidates all being voted upon in the same elecion on the same date. (FPPC Regulaion 18247.5)

New commitees: A new commitee formed within six months of a statewide regular elecion or within

30 days of a state special elecion is presumed to be primarily formed if the commitee makes at least $25,000 in independent expenditures to support or oppose a state candidate or measure. Monthly review is required for other new commitees that spend at

least $1,000 a month and were formed within six months of an elecion in connecion with which the commitee makes contribuions or expenditures.

Quarterly review at the end of March, June, September and December is required for other commitees.

A commitee controlled by a candidate for his or her own candidacy is not a primarily formed commitee.

Recall Commitees: A commitee supporing or opposing a recall must list the commitee measure’s itle, and the oiceholder’s name and oice. A recall commitee will mark whether it supports or opposes the oiceholder.

FPPC Form 410 (Dec/2012) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov

Statement of Organization Recipient Committee

INSTRUCTIONS ON REVERSE

COMMITTEE NAME

4. Type of Commitee

(Coninued)

CALIFORNIAFORM 410

Page 3

I.D. NUMBER

General Purpose Commitee

Not formed to support or oppose speciic candidates or measures in a single elecion. Check only one box:

CITY Commitee

COUNTY Commitee STATE Commitee

Sponsored Commitee

List addiional sponsors on an atachment.

NAME OF SPONSOR

INDUSTRY GROUP OR AFFILIATION OF SPONSOR

Instructions for Statement of Organization

CALIFORNIAFORM 410

General Purpose Commitee

A commitee is a “general purpose commitee” if its principal acivity is supporing or opposing a variety of candidates or measures voted on in diferent elecions. (FPPC Regulaion 18227.5)

•A state commitee makes contribuions or expenditures to support or oppose candidates or measures voted on in state elecions, or in more than one county; it does not make over 70%

of its contribuions or expenditures in a single local jurisdicion. State contribuions include contribuions to other state general purpose commitees. All poliical party commitees (including county central commitees) are state commitees.

•A county commitee makes more than 70% of its contribuions or expenditures to support or oppose

candidates or measures voted on in a single county, or in more than one jurisdicion within one county. This includes contribuions to other general purpose commitees in the same county.

•A city commitee makes more than 70% of its contribuions or expenditures to support or oppose

candidates or measures voted on in a single city, or in one consolidated city and county. This includes contribuions to other city general purpose commitees in the same city.

A city or county commitee may make up to four contribuions in a calendar year to candidates for elecive state oice whose districts are within the same jurisdicion and is not required to change status as a state commitee.

A commitee that has made contribuions or expenditures of $5,000 or more during a quarter must review its acivity at the end of March, June, September and December to determine if the commitee is iling reports in the appropriate jurisdicion. During the irst six months, a new

commitee must check its jurisdicional status each month the commitee makes expenditures of $1,000 or more. If a change of iling locaions occurs, reports must be iled in both the new and old jurisdicion through the calendar year.

Ater marking the appropriate state, county or city box, provide a brief descripion of the commitee’s poliical aciviies such as whether it supports candidates or measures that share a common poliical ailiaion.

Sponsored Commitee

A “sponsored commitee” is a general purpose or primarily formed commitee, other than an oiceholder or candidate controlled commitee, that has one or more sponsors.

An organizaion, business, or other enity is a sponsor if one or more of the following apply:

•The commitee receives 80% or more of its contribuions from the enity or organizaion or its members, oicers, employees, or shareholders.

•The enity or organizaion collects contribuions for the commitee by use of payroll deducions or dues from its members, oicers or employees.

•The enity or organizaion, alone or in combinaion with other eniies or organizaions, provides all or nearly all of the administraive services for the commitee.

•The enity or organizaion, alone or in combinaion with other eniies or organizaions, sets the policies for contribuion solicitaions or payment of expenditures from commitee funds.

See the instrucions for Part 1 for a sponsored commitee’s name requirements.

Small Contributor Commitee

A “small contributor commitee” is one that has been in existence for more than six months; receives

contribuions from 100 or more persons; makes contribuions to ive or more candidates; and has not received more than $200 from one person in a calendar year.

5. Terminaion Requirements

Recipient commitees may only terminate when:

•They have ceased to receive contribuions and make expenditures; and

•They do not anicipate receiving contribuions, repayments of outstanding loans made to others, or any other receipts in the future, and they do not anicipate making expenditures in the future; and

•They have eliminated or have no intenion or ability

to discharge all their debts, loans received, and other obligaions; and

•They have no funds; and

•They have iled all required campaign statements disclosing all reportable transacions, including disposiion of funds.

State Candidates: There are mandatory terminaion deadlines applicable to your commitees.

How to Terminate

State Commitees: Complete page one of the Form 410 and mark the terminaion box. Send the Form and last Form 450 or 460 (mark the terminaion box) to the Secretary of State.

Local Commitees: Complete page one of the Form 410, mark the terminaion box and send the Form to the Secretary of State. Send a copy of the Form 410 and last Form 450 or 460 (mark the terminaion box) to your city or county iling oicer.

FPPC Form 410 (Dec/2012) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov