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HomeMy WebLinkAboutForm 410 - COST TerminationSlaternient of Organization Recipient• Statement Type C] Initial Not yet qualified Q or Date qualified as committee 1. Committee Information NAME OF COMMITTEE Citizens Opposing San Rafael Target Type or print in ink Amendment List I.D. number: Date qualified as committee (If applicable) © Termination — See Part 5 List I.D. number: # 1339114 12 r 31 t 11 Date of Termination STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE San Rafael CA 94901 MAILING ADDRESS (IF DIFFERENT) Same OPTIONAL: FAX / E-MAIL ADDRESS COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE Marin None Attach additional information on appropriately labeled continuation sheets 2. Treasurer and Other Principal Officers NAME OF TREASURER Tamara Hull, CPA STREET ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE San Rafael CA 94903 NAME OF ASSISTANT TREASURER, IF ANY None STREET ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE None MAILING ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE 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,c f� Executed on 1/31/12 W DATE SIGN URE OF TREASUIJ,,tR ORASSISTANT TREASURER Executed on DATE Executed on DATE �1It:T.1 DATE N SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT BY SIGNVURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (Jan/01) FPPC Tall -Free Helnline: 866/A;SK-FPPC ,'Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME I.D. NUMBER Citizens Opposing San Rafael Target 1 1339114 4. Type o� ffCCommittee Complete the applicable sections. • •fiii • 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 "non-partisan." • If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. ELECTIVE OFFICE SOUGHT OR HELD NAME OF CANDIDfVElOFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY NIA I I I ❑ Non -Partisan • List the financial institution where the campaign bank account is located (controlled "candidate election" committees only) NAME OF FINANCIAL INSTITUTION ADDRESS AREA CODE/PHONE CITY BANK ACCOUNT STATE ZIP CODE Primarily formed to support or oppose specific candidates or measures in a single election. List below: Q Non -Partisan CAN OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE No On Target Referendum X FPPC Form 410 (Jan/01) FPPC Tall -Free Helpline: 866/ASK-FPPC Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Citizens Opposing San Rafael Target 4. Type of Committee (Continued) Not formed to support or oppose specific candidates or measures in a single election. Check only one box: Q CITY Committee ❑ COUNTYCommittee E] STATECommittee PROVIDE BRIEF DESCRIPTION OF ACTIVITY N/A .. . It . List additional sponsors on an attachment. NAME OF SPONSOR (INDUSTRY GROUP OR AFFILIATION OF SPONSOR N/A STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE I.D. NUMBER 1339114 n /_____I Check box and provide the date this committee qualified as a small contributor committee. If the committee qualified as a small Date qualified contributor committee on January 1, 2001, enter 1/1/01. 5. 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. -- Additional filing obligations will be incurred if, after terminating, the committee receives or spends any funds, or receives the forgiveness of a loan, repayments of loans made to others, or any other receipts. FPPC Form 410 (Jan/01) FPPC,Toll-Free Helpline: 866/ASK-FPPC