HomeMy WebLinkAboutForm 410 - Rachel Kertz for Board of Education 2018 TerminationStatement of Organization
Recipient Committee
Statement Type ❑ Initial
0 Not yet qualified
or
0 Date qualified as committee
K❑ Amendment 0 Termination — See Part 5
09 / 19 / 2018 12 / 27 / 2018
Date qualified as committee Date of termination
JAN 2 1 polg
CITY CLERK'S OFFir% s
For Official Use Only
1. Committee InformationI I.D. Number 2. Treasurer and Other Principal Officers
(if applicable) 1410420
NAME OF COMMITTEE NAME OF TREASURER
Chelsea Johnson
Rachel Kertz for Board of Education 2018 STREET ADDRESS IND P.O. BOX)
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
Roseville CA 95661 (
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
Roseville CA 95661 (
MAILING ADDRESS (IF DIFFERENT) STREET ADDRESS (NO P.O. BOX)
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.
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. 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 Pat the forgoing is true and correct.
Executed on 12/27/2018 By
DATE
OR ASSISTANT TREASURER
Executed on 12/27/2018 By
DATE ��� SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed onBy
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on
DATE
By
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
COMMITTEE NAME
Rachel Kertz for Board of Education 2018
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
First Foundation Bank
ADDRESS
AREA CODE/PHONE
CITY
(
BANK ACCOUNT NUMBER
STATE ZIP CODE
2233 Douglas Boulevard, Suite 300 Roseville CA 95661
4. Type of Committee Complete the applicable sections.
Page 2 page 2 of 4
I.D. NUMBER
1410420
• 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 MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
T I 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 MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
T I OPPOSE
OPPOSE
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization _1�17•]:�►1I:
Recipient Committee • '
INSTRUCTIONS ON REVERSE
71..
3 page 3 of 4
UMBER
Rachel Kertz for Board of Education 2018 I 1410420
4. Type of Committee (Continued)
General Purpose Committee 1 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
CITY
GROUP OR AFFILIATION OF SPONSOR
STATE ZIP CODE AREA CODE/PHONE
�. •7i%11[l Tiil7/ilpiUtR•Diliill•41:� ❑
/ /
Date qualified
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.
-- 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 1 1410420
Additional Mailing Address: San Rafael, CA 94903
www.netFiile.com