State of California Secretary of State STATEMENT OF FACTS ROSTER OF PUBLIC AGENCIES FILING (Government Code section 53051) Instructions: 1. 2. 3. 4. Complete and mail to: Secretary of State, P.O. Box 942870, Sacramento, CA 94277-2870 (916) 653-3984 A street address must be given as the official mailing address or as the address of the presiding officer. Complete addresses as required. If you need additional space, attach information on an 8½" X 11" page, one sided and legible. New Filing Legal name of Public Agency: Update (Office Use Only) Nature of Update: County: Official Mailing Address: Name and Address of each member of the governing board: Chairman, President or other Presiding Officer (Indicate Title): __________________________________________ Name: Secretary or Clerk (Indicate Title): Name: Members: Name: Name: Name: Name: Name: _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ Address: __________________________________________________ Address: __________________________________________________ Address: __________________________________________________ Address: __________________________________________________ Address: __________________________________________________ _________________________________________ Date __ Address: ___________________________________________________ __ Address: RETURN ACKNOWLEDGMENT TO: (Type or Print) NAME ADDRESS CITY/STATE/ZIP _________________________________________ Signature _________________________________________________ Typed Name and Title SEC/STATE NPSF 405 Rev 04/2015 American LegalNet, Inc. www.FormsWorkFlow.com