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HomeMy WebLinkAbout2013-08-07 Form 410 - HarnikStatement of Organization Recipient Committee Statement Type ❑ Initial Not yet qualified ❑ or _I- I Date qualified as committee 1. Committee Information 3. STATEMENT OF ORGANIZATION Type or print In Ink Date Stamp RECEIVED 10 CIT CLERK'S OFFICEIoForOffidalUse ® Amendment ❑ Termination —see Part 5 p, L M D E S E {; A List I.D. number. List I.D. number: # 1322067 # 2013 AUG -7 P8 3: 08 —�I I Date qualified as committee Date of Termination (If applicable) NAME OF COMMITTEE Re-elect Jan Harnik Palm Desert City Council 2014 STREETADDRESS (NO PO BOX) C;TY STATE ZIP CODE AREACODE/PHONE Palm Desert CA 92260 ( MAILING ADDRESS (IF DIFFERENT) same OPTIONAL: FAX / E-MA,LADDRESS COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE Riverside Attach additional information on appropriately labeled continuation sheets. 2. Treasurer and Other Principal Officers NAME OF TREASURER Dr. William Kroonen STREETADDRESS (NO PO BOX) CITY STATE ZIP CODE AREA CODEIPHONE Palm Desert CA 92260 ( NAME OF ASSISTANT TREASURER, IF ANY Elizabeth Lopez STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREACODE/PHONE Indio CA 92203 ( NAME OF PRINCIPAL OFFICER(S) STREETADDRESS (NO PO BOX) CITY STATE ZIP CODE AREACODE/PHONE Verification ' have used al reasonable di;igence in preparing this statement and to the best of my knowledge the information contained herein is true and complete. perjury under the aws of the State of California that the foregoing is true ar Executed on � 1 �`�By E Executed on Y':rI )61 -�D �C�r.5 By ATE Executed or. DATE Executed on DATE I certify under penalty of By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE FPPC Form 410 (April/2011) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE STATEMENT OF ORGANIZATION COMMITTEE NAME I.D NUMBER Re-elect Jan Harnik Palm Desert City Council 2014 1 1322067 4. Type of Committee Complete the applicable sections. • 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 "non -partisan." • 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 NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY Jan C. Hamik Councilmember / City of Palm Desert 2014 © Non -Partisan ❑ Non -Partisan • List the financial institution where the campaign bank account is located (controlled "candidate election" committees only) NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER FirstBank (760) 341-7000 ADDRESS CITY STATE ZIP CODE 73-000 Highway 111 Palm Desert CA 92260 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 (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE FPPC Form 410 (April/2011) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) Statement of Organization STATEMENT OF ORGANIZATION Recipient Committee CALIFORNIA41 ON INSTRUCTIONS ON REVERSE Page 3 Re-elect Jan Harnik Palm Desert City Council 2014 1322067 4. Type of Committee (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 PROVIDE BRIEF DESCRIPTION OF ACTIVITY List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREETADDRESS NO AND STREET CITY ❑ 1_J Date qualified 5. Termination Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent 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 (April/2011) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) Statement of Organization STATEMENT OF ORGANIZATION Recipient Committee Type or print in ink Date Stamp Statement Type ❑ :nitia: Not yet qualified ❑ or ® Amendment List I D. number. 1322067 ❑ Termination —See Part 5 ECEi10E® AND FCL List I.D. number: i the office of the Secretary of of the State of Califomia � , _1 1 1 AUG 0 9.2013 Date qualified as committee Date qualified as committee Date of Termination (If applicable) I AUG 19 flIq 10: czo f_I,iJlrc/',i; JF U,i1EitS "'OU TY OF LRSIDE 1. Committee Information 2. Treasurer and Other Principal Officers NAME OF COMMITTEE NAME OF TREASURER Re-e:ect Jan Harnik Palm Desert City Council 2014 STREET ADDRESS (NO PO BOX) CITY STATE ZIP CODE AREA CODE/PHONE Pa'm Desert CA 92260 ( MAIUNG ADDRESS (IF DIFFERENT) same OPTIONAL: FAX/E-MA!LADDRESS COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE Riverside Attach additional information on appropriately labeled continuation sheets Dr. William Kroonen STREET ADDRESS (NO PO BOX) CITY STATE ZIP CODE AREA CODE/PHONE Palm Desert CA 92260 ( NAME OF ASSISTANT TREASURER, IF ANY Elizabeth Lopez STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREACODE/PHONE Indio CA 92203 ( NAME OF PRINCIPAL OFFICER(S) STREET ADDRESS (NO PO BOX) CITY STATE ZIP CODE AREACODE/PHONE 3. Verification o �� I have ::sed all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and complete. I certify und26penoftprof perjury under the aws of the State of California that the foregoing is true and OR ASSISTANT TREASURER 3T Executed on��%� _ A TE gy - - - - cn m Executed on g C' T DATE y SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE. OR STATE MEASURE PROPONENT � n Executed on By m DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (April/2011) FPPC Toll -Free Helpline• 866/ASK-FPPC (8661275-3772) STATEMENT OF ORGANIZATION CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE ('NCLUDE BALLOT NO. OR LETTER) Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Re-elect Jan Harnik Palm Desert City Council 2014 4. Type of Committee Complete the applicable sections. Controlled Committee I.D. NUMBER 1322067 l • List the name of each controlling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled, also list the eectiffice ve osought 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 "non -partisan." • 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 NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY ❑X Non -Partisan Jan C. Harnik Councilmember / City of Palm Desert 2014 • List the financial institution where the campaign bank account is located (controlled "candidate election" committees only) NAME OF FINANCIAL INSTITUTION FirstBank ADDRESS AREA CODE/PHONE (760) 341-7000 CITY 462-120- CODE 73-000 Highway 111 Palm Desert CA 92260 .1 , Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) Non -Partisan CHECK ONE FPPC Form 410 (April/2011) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)