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Form 410- Yes on Measure D TerminationStatement of Organization Recipient Committee Da :c St a m p CALIFORNIA 41 0 FORM Statement Type D Initial Not yet qua lifi ed 0 or -----/----~/----- o Amendment list I.D. n umber: It 1383895 ----/---~/---- Date q ual ified as committee Dat e q ualified as committee 111.pp .".ble] 1. Committee Information IZl Termination-See Part 5 RE EiVED AND F:LED list 1.0 . number: i It 1383895 08 Date of Termination n the ffice of the Secretary of State f the State of California SEP 0 1 2016 2. Treasurer and Other Principal Officers NAME OF iREASIw~Eq Committee to Support San Rafael Libraries -Yes on Measure 0 Dirck W. Brinckerhoff S,REET A O~RE SS (NO po 30X] 1000 4th Street , Ste. 600 San Rafael CA 94903 c.r"" ZI . COU~ AREA COOEj;:H C !\:: San Rafael CA 94901 ( Jeffrey Schappert .REET A ju~ESS (~O PO aox] 1000 4th Street, Suite 600 ZIP COuE NAME 0' PR INCIPAL Of';CER(S] Marin San Rafael Jeffrey Schappert STRE ET ADDRESS {~O PO SOX] CIT V ZIP CODE Attach additiona l information on appropriately labeled continuation sheets. San Rafael CA 94901 3. Verification For OffiCIa l Use On ly A~::A CODE/?~Of\E ( AiH:A CO:lE/:JrlONE ( A;{f A COJ E/;J~ON E ( 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 al ifornia that the foregoing is true and correct. ~~on4~4D~~l~~-_Ll~~gC====~'==s;G;2~r~,u~RE~0~F=~~~~S~UR~E~R~OR-A~H~'5=Th~~=T ~ffi~~~W~R=ER~--------------- Executed on DAT E Executed on CATE Executed on ~ATE By By By SIGNATURE Of CONTRCtUNG OffiCEHOLDER. CANDIDATE. OR STATE MEASURE PROPO N ENT SIGNATURE Of CO'lTROlUNG OFFICEHOLDER. CAND IDATE , OR 5 ATE MEASURE PROPON ENT SIGNATU~E Of CONTROLLING OfFICH1OLDER, CAN~IDATE . OR STATE I\'EASURE PROPONENT FPPC Form 410 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee Termination 8-15-2016 Committee to Support San Rafael Libraries -Yes on Measure 0 Continuation sheet: 2. Treasurer and Other Principal Officers Additional Principal Officer: Glena Coleman San Rafael, CA 94901 ( California Form 410 Page 1-A 10 Number: 1383895 Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Committee to Support San Rafael Libraries -Yes on Measure D • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE Bank of Marin (415)485-2265 ADDRESS CITY BANK ACCOUNT NUMBER 02345205 STATE ZIP CODE CALIFORNIA 41 0 FORM 1.0. NUMBER 1383895 1101 4th Street San Rafael CA 94901 4. Type of Committee Complete the applicable sections. ~~----- Controlled Committee • 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 "nonpartisan." • If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION Primarily Farmed Committee 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 LEITER) San Rafael Special Library Services Parcel Tax Measure CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) City of San Rafael PARTY o Nonpartisan o Nonpartisan CHECK ONE SUPPORT OPPOSE [l] D sur:l °Ll FPPC Form 410 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov