HomeMy WebLinkAbout2021-11-23 Form 410 - HarnikRFt,i;:lvl=n amn mi Fn
Statement of Organization
in
the office op*0620retary of 91,
of the State of Cali om `
CALIFORNIA
410
Recipient Committee
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.
FORM
Statement Type i]Inldal ®Amendment
❑Termination—See.PartS
DEC 13��(} �"
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O Date qualification threshold met Date qualification threshold met
Date of termination I
land Delivered,FSa$iafne
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11 r 23 / 2021
Committee1. E I.D. Number l3 2� obi
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Other P,rinciTal Officers
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-NAMEOFCOMMITTEE -
NAMf Of TRFASURER
Re -Elect Jan Harnik Palm Desert City Council 2022
Jan Harnik
STREET ADDRESS IND P.O. BOSS -
-
STREET ADDRESS (NO P.O. SOX)
COY
STATE
ZIPCODE AREACODE/PHONE
Indian Wells
CA
92210
CITY STATE ZIPCODE AREACODE(PHONE
NAME OF ASSISTANT TREASURER IF ANY
Indian We -Us CA 92210
Bryan Burch
FULL MAILING ADDRESS (IF DIFFERENT)
STREET ADDRESS (NO P.D. SOAI
West Sacramento, CA 95799
EMAIL ADDRESS (REQUIRED)/I"(OmONAL)
CITY
STATE
ZIP CODE - A0.[A r-0OF/PNONE
West Sacramento
CA
95799
COUNTT OF DOMICILE
JURISDICTION WHERE COMMITTEE IS ACTIVE
NAME OF PRINCIPAL OFFICER(S)
Riverside
City of Palm Desert
STREET"DRESS (NO P.O. BOX)
Attach additional information on appropriately labeled continuation sheets.
CITY STATE
ZIPCODE AREACODE(PHONE
3.7 Verification
IIICYGUDC..11'TU,..s..L,CI.,NICFO ....& LI IID. D,OLC:I I ICI IL 01 JU L LI IC Un CSL UI I I Iy M IUWICU6C IF It IIUI nFI IdU%j.0 UECnm leo nereis True ano comp) ere.!.. ceMTV under
penalty of periury under the laws of the State of california th he foregai7 i and correct.
Executed on
DATE Y.__
Executedon By
DATE
Executed on By
DATE SIGNATURE OF CONTROW NG OFFICEHOLDER CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (August/20181
FPPC Advice: advice(MODc.ca.eov (866/275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
2
Re -Elect Jan. Harnik Palm Desert City Council 2022
R All committees must list the financial Institution where the campaign bank account is located.
NAME OF FIMANCIALINSTITUTON
AREACODUPHONE
aANCACCOUNTNUMBIR
California Bank and Trust
(
ADDRESS
CITY
STATE TIPCODE
550 S. Hope St.,, Ste. 300
Los Angeles
CA
90071
E
• 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/OFFICENOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION
CXCCRONE
"
Jan Harnik
City of Palm Desert
2022
Nonpartisan
1
Partisan
(list political party. below)
Nonpartisan
Partisan
(list political party below)
Primarily formed to support or oppose specific candidates or measures In a single election. List below:
CAN DIDATE(s) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
CANOIDATE(S) OFFICE SOUGHT OR HELD OR MEASU REIS) JURISDICTION
_....__...__.._—_.._......._.
SO PPORT
.OPPOSE
SUPPORT
- OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppe.ca.gov (W/275.3772)
www.fppc.a.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 3 of 3
Re -Elect Jan F:arnik Palm Desert C_cy Council 2022
(COntinued)
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee
PRDv IDE SR If DESCRIPnON Of AC➢vrtr
List additional sponsors on an attachment.
"ME OF SPONSOR
SPONSOR
STREETADDR!SS NO. ANDSTREET CITY STATE EIP CODE
❑/
Du. c�Rim.a
5. Termination Requirements Byslgningthe wrification. the treasurer, assistanttreasurarand/or Candidate, officehootror proponent cerhfy that all of the following con III It ons have been nuic
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 maybe 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.
WPC Form 420 (August/2018)
FPPC Advice: adviceefppc.m.gov ("6/275.3772)
www.fppc.ca.gov