HomeMy WebLinkAboutForm 410 - Rachel Kertz for Board of Education 2018 Amendment (2018-09-28)Statement of Organization
Recipient Committee
Statement Type ❑ Initial Amendment ❑ Termination — See Part 5
Not yet qualified
or
0 Date qualified as committee
Date qualified as committee Date of termination
Date Stamp
ECEIVED AND Fil
the office of the Secretary of
of the State of California
SEP 2 8 2018
1. Committee Information I.D. Number 2. Treasurer and Other Principal Officers
(if applicable) �" N
NAME OF COMMITTEE
Rachel Kertz for Board of Education 2018
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
Roseville CA 95661 (
MAILING ADDRESS (IF DIFFERENT)
E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL)
(
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
Marin City of San Rafael
Attach additional information on appropriately labeled continuation sheets.
Chelsea Johnson
For Official Use Only
STREET ADDRESS (NO P.O. BOX)
CITY
Roseville
STATE
CA
ZIP CODE
95661
AREA CODE/PHONE
(
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY
STATE
ZIP CODE
AREA CODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY
STATE
ZIP CODE
AREA CODE/PHONE
3. Ver' ication
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 Calif:171
that the foregoing is true and correct.
Executed on V _ By ✓/—
DTE _AL"ATURE OF TREASURER OR ASSISTANT TREASURER
Executed on �/ ��� By
DATE SIGNATURE OF DONR`ROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on I By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410(February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Pagel Page 2 of 4
COMMITTEE NAME
I.D. NUMBER
Rachel Kertz for Board of Education 2018 1410420
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
First Foundation Bank (
ADDRESS CITY STATE ZIPCODE
Roseville CA 95661
4. Type of Committee Complete the applicable sections.
• 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." Stating "No party preference" is acceptable.
• 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 YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION
CHECK ONE
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURES) FULLTITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE "RECALL" IN FRONT OFTHE OFFICEHOLDER'S NAME.
CANDIDATES) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
T OPPOSE
OPPOSE
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Board of Education: City of San Rafael
Nonpartisan
Partisan
(list political party below)
Rachel Kertz
2018
X
Nonpartisan
Partisan
(list political party below)
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURES) FULLTITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE "RECALL" IN FRONT OFTHE OFFICEHOLDER'S NAME.
CANDIDATES) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
T OPPOSE
OPPOSE
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Rachel Kertz for Board of Education 2016
4. Type of Committee (Continued)
General Purpose Committee i Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee ❑ Political Party/Central Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
❑ / W.
Date qualified
CITY
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
Page3 page 3 of 4
I.D. NUMBER
1410420
STATE ZIP CODE AREA CUUp MUNI:
S. 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.
-- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511- 89518, and are
subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Additional Comments
For Form 410
ADDITIONAL COMMENTS
Page 4 of 4
COMMITTEE NAME I.D. NUMBER
Rachel Kertz for Board of Education 2018 1410420
Additional Mailing Address:
www.netFle.com