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Form 410- Yes on Measure D AmendmentStatement of Organization Recipient Committee Statement Type o Initial Not yet qualified r;z] or --~/--_J!--~ Date qualified as committee 1. CorTu;nitt.ee.l nformation NAME OF COMMITTEE I;zJ Amendment List I.D. number: # 1383895 03 /09 /2016 Date qualified as committee (If applicable) o Termination -See Part 5 List I.D. number: #_------~ ---j!--~/--~ Date of Termination 2. Tre~surer-a NAME OF TREASURER Committee to Support San Rafael Libraries -Yes on Measure 0 Dirck W. Brinckerhoff STREET ADDRESS (NO P.O. BOX) STREET ADDRESS (NO P.O. BOX) CITY 1000 4th Street, Ste. 600 San Rafael CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY San Rafael, CA 94901 ( Jeffrey Schoppert MAILING ADDRESS (IF DIFFERENT) STREET ADDRESS (NO P.O. BOX) P.O. Box 150488, San Rafael, CA 94915 FAX / E'MAIL ADDRESS CITY San Rafael COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(S) Marin City of San Rafael Jeffrey Schoppert STREET ADDRESS (NO P.O. BOX) CITY Attach additional information on appropriately labeled continuation sheets. San Rafael STATE ZIP CODE AREA CODE/PHONE CA 94903 ( STATE ZIP CODE AREA CODE/PHONE CA 94901 ( STATE ZIP CODE AREA CODE/PHONE CA 94901 ( -3. Verification .:. ,.' "., _ . 1 •• :, . f have' used a il rea sonable "d'fi igence in 'p(;paring t his -state iTIent a ~d to the -bestof" my kn-ow ledge the information~c-onta 'in;d herein is'-tr~e a~d complete: I c ertifY 'under penalty of perjury under the laws of the State f California that the foregoing is true and correct. ~~oo OY1m016 ~-1~([===~=='~-~~~==~====-----------SIGNATURE OF TREASURER OR ASSISTANT TREASURER DATE Executed on DATE By Executed on By DATE Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER , CANDIDATE, OR STATE MEASURE PROPONEN T SIGNATURE OF CONTROlLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT SIGNATURE OF CONTROLLING OFFICEHOLDER , CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov '. Statement of Organization Recipient Committee Amendment 3-18-2016 Committee to Support San Rafael Libraries -Yes on Measure D Continuation sheet: 2. Treasurer and Other Principal Officers Additional Principal Officer: Glena Coleman San Rafael, CA 94901 ( California Form 41 0 ID Number: 1383895 '. Statement of Organization Recipient Committee INSTRUCTIONS or~ REVERSE CO MM IT EE rHIME Committee to Support San Rafael Libraries -Yes on Measure 0 • All committees must list the financial institution where the campaign bank account is located. r ~At.~E O F FINAflC'Allt~S T TL T l0 ~J AREA CODE/PHO~JE Bank of Marin (415)485-2265 ADDRESS 1101 4th Street San Rafael 4. Type of Committee Complete the applicable sections. Controlled Committee O.;r'K ACCOUIlT 'lUMBER STATe :IP CODE CA 94901 CALIFORNIA 41 0 FORM r D NUr.18ER 1383895 • List the name of each controlling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled, also list the electlVe office sought or held, and district number, If any, and the year of the election . • List the political party w i th which each officeholder or candidate is affiliated or check "nonpartisan." • If this committee act s jointly with another controlled committee, list the name and identification number of the other controlled committee NAME OF CANDIDATE/OFFICEHOLDER/STAlE MEASURE PROPONENT ELECTI V E OFFICE SOUGHT O R HE LD (INCLUDE DISTRICT NUMBER IF APPLIC A BLE) YEAR OF ELECTION Primarily Formed Committee ~ . Prima rily formed to sup port or oppo se specific candidates or measures In a smgle election . List below: CANDIDATEiS) NAME OR M EASURE(S) FULL TI TL E (II e l.UDE BALLOT NO O R LETTER) San Rafael Special Library Services Parcel Tax MeasureO CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASUR~(~) JURIS[)ICTION IINllUDE DISTRICT NO , CITY OR COUNTY, A5 APPLICABLE) City of San Rafael PAR T; o Nonpartlsan o Nonparnsan CHECK O~Jr: . - S U ~PORT OPPOSE 0 D 5l0 l 00 FPPC Form 410 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRU CTIONS ON REVERSE C OMr~lnEE N"ME Committee to Support San Rafael Libraries -Yes on Measure 0 4. Type of Com!!,ittee (Continued) CALIFORNIA 41 0 FORM 10 NUMBER a 1383895 General Purpose Committee . -Not formed to support or oppose specific candidates or measures in a single electlO n. Check only one box : o CITY Committee 0 COUNTY Committee 0 STATE Committee pQOVloe BRIEF DESCRIPTIOU 0;: ACTIVITY Sponsored Committee . List add i tional sponsors on an attachment. flAME Of SPONSOR !NDUSTRY GROUP OR AFFllIATlC~~ OF sPo,.SOrt ~TREn ~DD"ESS NO AND STR(ET cln ZIP C~DE Small Contributor Committee -0_-1_-1 __ 5. Termination Requirements By signing the verification, the treasurer,_ assist~nt treasurer and/or candlda~, officeholder, or proponent certify that all of the following conditlons 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 re ceived, and other ob ligations; • This committee has no surplus funds; and • This committee has filed all campa ign statements requ i red by th e Political Reform Act disclosing all reportable transactions . --There are restrictlons on the disposition of surplus campaign funds held by elected officers who are leavin g 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 Section s 89511 -89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5. FPPC Form 410 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov