HomeMy WebLinkAboutForm 410 - Maribeth Bushey; 08/16/2022 State�✓l I� _Date Stamp
Statement of Organization H 5 Z, V 3 -
Recipient Committee
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Statement Type Initial ❑ Amendment ❑ Termination — See Part 5 of the State of Califomla
0 Not yet qualified
or AUG17 2022
0 Date qualification threshold met Date qualification threshold met Date of termination
• I.D. Number • • • •
FC8 TRIal
CITY CLERK'S
NAME OF COMMITTEE NAME OF TREASURER
Re-elect Maribeth Bushey San Rafael City Council District 3 2022 Mark L. Kyle
STREET ADDRESS (NO P.O. BOX)
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
San Rafael CA 94901
CITY STATE ZIPCODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
San Rafael CA 94901
FULL MAILING ADDRESS (IF DIFFERENT) STREET ADDRESS (NO P.O. BOX)
E-MAIL ADDRESS(REQUIRED)/FAX(OPTIONAL) CITY STATE ZIP CODE AREA CODE/PHONE
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPALOFFICER(S)
Marin I City of San Rafael
Attach additional information on appropriately labeled continuation sheets.
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
I have used all reasonable diligence in preparing
PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING 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 C&fppc.ca.eov (866/275-3772)
www.fppc.ca.gov
Statement of Organization CALIFORNIA
Recipient Committee FORM
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D. NUMBER
Re-elect Maribeth Bushey San Rafael City Council District 3 2022
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 415-485-2275
ADDRESS CITY STATE ZIP CODE
1101 Fourth Street San Rafael CA 94901
• 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
Maribeth Bushey
City of San Rafael, City Council, District 3
2022
Nonpartisan
Partisan
(list political party below)
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
SUPPORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: adviceMooc.ca.aov (866/275-3772)
www.fooc.ca.eov