HomeMy WebLinkAboutForm 410 - Rachel Kertz for Board of Education 2018 Termination AmendStatement of Organization
Recipient Committee
Statement Type ❑ initial x❑ Amendment
Q Not yet qualified
or �0/ 19 / 2018
0 Date qualified as committee
Date qualified as committee
1. Committee InformationI I.D. Number
(if applicable) 1410420
NAME OF COMMITTEE
Rachel Kertz for Board of Education 2018
❑x Termination — See Part 5
12 / 27 / 2018
Date of termination
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.
Date Stamp
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FE3 012x'13
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Chelsea Johnson
STREET ADDRESS (NO P.O. BOX)
Ir OfficRely
FEF 1 1, 201
CITY STATE ZIP CODE AREACODE/PHONE
Roseville CA 95661 (
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREACODE/PHONE
NAME OF PRINCIPAL OFFICERS)
STREET ADDRESS (NO PO. BOX)
CITY
STATE ZIPCODE AREACODE/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 for is true and correct.
Executed on 12/27/2018 By j/ ✓%`
DATE �URE'OF TREASURER OR ASSISTANT TREASURER
Executed on 12/27/2018 By
DATE —T%— ' SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
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 CALIFORNIA,
Recipient Committee •
INSTRUCTIONS ON REVERSE
Page z 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 ZIP CODE
4. Type of Committee Complete the applicable sections.
Roseville
CA 95661
• 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 Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATES) NAME OR MEASURES) FU LL TITLE (INCLUDE BALLOT N0. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT 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 Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATES) NAME OR MEASURES) FU LL TITLE (INCLUDE BALLOT N0. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT I 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
COMMITTEE NAME
Rachel Kertz for Board of Education 2018
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 ❑ Political Party/Central Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee 1 List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
CITY
GROUP OR AFFILIATION OF SPONSOR
Page 3 page 3 of 4
I.D. NUMBER
1410420
STATE ZIP CODE AREACODE/PMONE
ContributorSmall • ❑
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 (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.netriile.com