HomeMy WebLinkAboutForm 410 - Carolina Martin for San Rafael School Board Trustee 2022Statement of Organization
Recipient Committee
Statement Type ❑x Initial ❑ Amendment
® Not yet qualified
or
0 Date qualification threshold met Date qualification threshold met
❑ Termination —See
Date of termination
JUN 2 9 2022
CLERK'S OFFIC
For Official Use Only
1. Committee'Information I.D. Number 2. Treasurer andOther Principal Officers
(if applicable)
NAME OF COMMITTEE NAME OF TREASURER
Carolina Martin for San Rafael City Schools District 4 2022 Chelsea Johnson
STREET ADDRESS (NO P.O. BOX)
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
Antelope CA 95843 (
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
Antelope
FULL MAILING ADDRESS (IF DIFFERENT)
E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL)
CA 95843 (
COUNTY OF DOMICILE I 711 R15DI MON WHERE COMMITTEE
Marin
City of San Rafael
Attach additional information on appropriately labeled continuation sheets.
STREET ADDRESS (NO P.O. BOX)
CITY
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO RO. BOX)
STATE ZIP CODE AREA CODE/PHONE
C TY STATE ZIP CODE AREA CODE/PHONE
3. Verification
I have used all reasonable diligence in preparing this
PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
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
COMMITTEE NAME
Carolina Martin for San Rafael City Schools District 4 2022
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
First Foundation Bank
ADDRESS
AREA COD E/PHON E
(93.6)724-2424
CITY
BANK ACCOUNT NUMBER
STATE ZIP CODE
2233 Douglas Blvd., Ste. 300 Roseville CA 95661
4. Type of Committee Complete the applicable sections.
I.D. NUMBER
2 of 4
• 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
Carolina Martin
Board of Education City of San Rafael
District 4
2022
Nonpartisan
X
Partisan
(list political party below)
Nonpartisan
Partisan
(list political party betow)
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULLTITLE (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 (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 of 4
COMMITTEE NAME
Carolina Martin for San Rafael City Schools District 4 2022
4. 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
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODEJPHONE
Contributor r ❑
Date qualified
5. Termination Requirements By signing the verification, the treasureri assistantitreasurer and/orcandidate, officeholder, or roponentcertify that all ofthe followingxonditions'-have been 'met:
r, 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
Additional Comments
For Farm 410
Carolina Martin for San Rafael City Schools District 4 2022
Additional Mailing Address: San Rafael, CA 94901
www.neifile.com
ADDITIONAL COMMENTS
Page 4 of 4
D. NUMBER