HomeMy WebLinkAboutForm 410- Paramedic Services PAC; TerminateStatement of Organization Datestam ROfficial
Recipient Committee D` C E a d
Statement Type ❑ initial ❑ Amendment ® Termination — See Part 5 MFly
Q Not yet qualified JAN 2 9 2020
or
0 Date qualification threshold met Date qualification threshold met Date of termination
/ / /� 01 /� 202o CITY CLERK'S OF lu
3. Committee Information I.D. Number 1075199 2. Treasurer and Other Principal Officers
(if applicable)
NAME OF COMMITTEE NAME OF TREASURER
Committee for San Rafael Paramedic Services Greg Knell
STREET ADDRESS (NO P.O. BOX)
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
San Rafael CA 94903
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
San Rafael CA 94903
FULL 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 County City of San Rafael
Attach additional information on appropriately labeled continuation sheets.
I have used all reasonable diligence in preparing this statement and t he best
penalty of perjury under the laws of the State of California that th regoing is
Executed on 01/29/2020 By
DATE
Executed on 01/29/2020 By
DATE
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
contained herein is true and complete. I certify under
NT
SIGNATURE OF COPTROVNG OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
® P y www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME
I.D. NUMBER
Committee for San Rafael Paramedic Services
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE
ADDRESS CITY STATE ZIP CODE
1101 4th St San Rafael CA 94901
14. Type of Committee Complete the applicable sections.
1075199
• 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 Committee I 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 APPLICARLE)
SUPPORT
1-1
Nonpartisan
Partisan
(list political party below)
T
SU[:]
OPPOSE
Nonpartisan
Partisan
(list political party below)
El
F71
I
Primarily Formed Committee I 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 APPLICARLE)
FPPC Form 410(August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
SUPPORT
1-1
OPPOSE
EL
T
SU[:]
OPPOSE
FPPC Form 410(August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 3
I.D. NUMBER
Committee for San Rafael Paramedic Services
Type of Committee (Continued)
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
® CITY Committee ❑ COUNTY Committee ❑ STATE Committee
1075199
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Support Paramedic Service Special Taxes in Sam Rafael
SponsoredList additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREETADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE
l7iiUllfi4AN717►irlit 7i71u7iiFra
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 maybe 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 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov