HomeMy WebLinkAboutForm 410- Maribeth Bushey for City Council 2017 Amendment #2Sta.tement of Organization
Recipient Committee
Statement Type o Initial
Not yet qualified 0 or
--I I
Dale qualified as committee
1. Committee Information
NAME OF COMMITTEE
Ii21 Amendment
List 1.0 . number:
#1358370
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Date qualified as committee
(If applicable)
Maribeth Bushey For San Rafael City Council 2017
STREET ADDRESS (NO P.O. BOX)
Date Stamp CALIFORNIA 41 0
FORM
o Termination -See Part 5
List 1.0 . number:
#---------------
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Date ofTermination
RE EIVE ,,\ AN'" r lL D . U I .L) r.
In th office of the Secretary of St Ie
of the State of California
SEP 092016
2. Treasurer and Other P~incipal Officers
NAME OF TREASURER
Mark Kyle
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE
San Rafael CA 94901
For Official Use Only
AREA CODE/PHONE
(
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANTTREASURER.IF ANY
San Rafael CA 94901 (
MAILING ADDR ESS (IF DIFFERENT) STREET ADDRESS (NO P.O. BOX)
FAX I E-MAil ADDRESS CITY
COUNTY OF OOMICllE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OfFICER(S)
Marin City of San Rafael
STREET ADDRESS (NO P.O. BOX)
CITY
Attach additional in/ormation on appropriately labeled continuation sheets.
3. Verification
I have used all reasonable diligence in preparing thi
penalty of perjury under the laws of the State of
Executed on 09/05/2016
DATE
Executed on 09/05/2016
DATE
By
Executed on BV
DATE
Executed on By
DATE
SIGNATURE OF CONTROlLING OFfiCEHOlDER, CANDIDATE , OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROlliNG OFFICEHOLDER. CANDIDATE, OR STATE MEASURE PROPONEN T
STATE ZIP CODE AREA CODE/PHONE
STATE ZIP CODE AREA CODE/PHONE
I certify under
FPPC Form 410 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3712)
www.fppc.ca.gov
S~atement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
'fVr~rm~'¥I1EBushey For San Rafael City Council 2017
CALIFORNIA 41 0
FORM
1.0. NUMBER
1358370
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
Bank of Marin (
ADDRESS CITY STATE ZIP CODE
San Rafael CA 94901
4. Type of Co~"'.:'ittee Complete the applicable sections.
Controllcd Committee
• 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."
• If this committee acts jOintly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELO
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION
Maribeth Bushey San Rafael City Council 2017
Primarily Formed Committee 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) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
PARTY
o Nonpartisan
o Nonpartisan
CHECK ONE
SUPPORT OPPOSE D D
FPPC Form 410 (Jan/2016)
FPPC Advice: advlce@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
