Statement of Organization Recipient Committee

Form 410 Instructions

Part 1 of 6: Type of Statement

Statement Type











Part 2 of 6: Committee Information

Attach additional information on appropriately labeled continuation sheets.













Part 3 of 6: Treasurer and Other Principal Officers






















Part 4 of 6: 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.





Please print and have the treasurer or assistant treasurer sign the top line. The next 3 signatures must be from the controlling officeholder, candidate, or state measure proponent.


Next Page

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









Part 5 of 6: Type of Committee

First Controlled Committee

  • List the name of each controlling officeholder, candidate, or state measure proponenet. If candidate or officeholder controlled, also list the elective office souch 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.




Second Controlled Committee

  • List the name of each controlling officeholder, candidate, or state measure proponenet. If candidate or officeholder controlled, also list the elective office souch 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.




First Primarily Formed Committee

Primarily formed to support or oppose specific candidates or measures in a single election.




Second Primarily Formed Committee

Primarily formed to support or oppose specific candidates or measures in a single election.




General Purpose Committee

Not formed to support or oppose specific candidates or measures ina single election. Check only one box:




Sponsored Committee

List additional sponsors on an attachment.








Small Contributor Committe




Part 6 of 6: 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.

Please press 'Create PDF Document' button below. Filled out Form 410 PDF document will be opened. Please print the document and sign at the bottom of the page.


End of Page, Form 410.