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Form 410- Yes on Measure D InitialStatement of Organization Recipient Committee Statement Type ❑ Initial ❑ Amendment List I.D. number: Not yet qualified 10or q ❑ Termination —see Part 5 List I.D. number: ID I [E C 'LE 0 W MAR 1 0 2016 .1 .1 �.1 1 CITY CLERK'S OFF CE Date qualified as committee Date qualified as committee Date of Termination (If appilable) 1. Committee Information 2. Treasurer and Other Principal Officers NAME OF COMMITTEE NAME OF TREASURER Committee to Support San Rafael Libraries - Yes on Measure STREET ADDRESS (NO P O BOX) 1000 4th Street, Ste. 600 CITY STATE ZIP CODE AREA CODE/PHONE San Rafael, CA 94901 ( MAILING ADDRESS (IF DIFFERENT) P.O. Box 150488, San Rafael, CA 94915 FAX / E-MAIL ADDRESS COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE Marin I City of San Rafael Dirck W. Brinckerhoff STREET ADDRESS (NO P.O BOX) For Official Use Only CITY STATE ZIP CODE AREACODE/PHONE San Rafael CA 94903 ( NAME OF ASSISTANT TREASURER, IF ANY Jeffrey Schoppert STREET ADDRESS (NO P.O BOX) CITY STATE ZIP CODE AREACODE/PHONE San Rafael CA 94901 ( NAME OF PRINCIPAL OFFICERIS) Jeffrey Schoppert STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE Attach additional information on appropriately labeled continuation sheets. San Rafael CA 94901 ( 3. 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. Executed on Z-6 ( G BY I DATE RER OR Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT Executed on BY GATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (tan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee Continuation sheet: 2. Treasurer and Other Principal Officers Additional Principal Officer: Glena Coleman San Rafael, CA 94901 ( California Form 410