HomeMy WebLinkAboutForm 410- Lucia Martel Dow for San Rafael School Board 2022; Terminationabout:blank
irefox
DocuSign Envelope ID: 51 B94C71 AD75-4C56-8BCD-24F0534BA4AA
Statement of Organization
Recipient Committee
Statement Type r
nitial 0 Amendment [h] Termination - See PaFor Off Ua1 lase Only
Not yet qualified°` ITYCL ERK'S OFFI�EDate qualification threshold met Date qualifl€cation threshold met Dale ofterminati
30 1_&o 2 12 ! 31 1 2022
1. Committee Information I.Q. Number 1442H92. Treasurer and Other Principal Officers
(if applicable)
NAME OF TREASURER
NAME OF COMMITTEE
Lucia Martel Dow, for Sar Rafael School Board 2022 Lucia Martel Doi.;
MEET ADDRESS INC) P.O. OOxI
STREET ADDRESS(Ad P.O. 90x) 'n STATE ZIP CODE AREA CODEPPAGNE
CITY STATE ZIPCODE AREACODEIPHONE
Novato CA 94949-5733 {
FULLMAKINGADDAESS HF DIFIERENn
E-MAIL ADDRESS (RE4U IRE 0) f FAX{OPMN4tl
MUNTY OF DOMICILE 1 JURISDICTION wHERE coMMITTEE IS AC
Marin County f San Rafael
Attach additional information on appropriately labeled continuation sheets.
40vato CA 94945-5731 (
NAW.E OF ASSISTAN''TTREASURM IF AW
Nancy L Warren
STREET ADDRESS WD PO, BOY)
CITY STATE ZIPCODE AREA COD EJPHIXiE
Novato CR- 94949-5J31 (
N"..F OF PRINCIPAL OFFICE R(S)
STREET ADDRESS WO PD. BOX]
CITY STATE ZIP CODE AREA CODE/P::ONE
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 that the foregoing is true and correct.
Executed on 1/28,12023 By
DATE
Executed on 1/23/2023 By
DATE
Executed onBY
CAT£ SIGNATURE OF CDNTRDLLIN&OFFICEHOLDER. CANDIDATE, OR STATE MEASURE PROPONENT
Executed on BY
DATE SIGNATURE OF COl1TROLUNG O FFICEHOLpER, CAN OIg1ATE, OR STATE W. EMU RE P ROPONEIlT
FPPC Form 410 {August/2018}
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
nef/Ile. Coll)
1 ..F 4
1 II.nc nre
refox
about:blank
DOCUSign Envelope ID: 51B94C71-AD75-4056-8BCD-24F0534BA4AA
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
;A W-rt,1 now for San Rafael school Board 2022
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
aanlr nr SAn Francisco
AREA CODE/PHONE
(415)744-6700
CITY
BANK ACCOUN I NUMU-
STATE ZIPCODE
I.D. NUMBER
1442869
ADDRESS
575 Market Street e900
San Francisco CA 94105
4. Type of Committee Complete the applicable sections.
• List thenameof 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 CAN MEASURE PROPONENT (INCLUDE_ DISTRICT NUMBER IF APPLICABLE) ELECTION CHECK ONE
Nonpartisan Partisan {list pal➢deal parry belOw)
Lucia Martel Dopa School Board City of San Rafael 2022 X
:J Nonpartisan PartlSanPrimarily Formed Committee (list politica{ parry 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) 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 p4PC5f
FPPC Form 410 (August/2018)
FPPCAdvice; advice@fppc.ca.gov (86G/275-3772)
www.fppc.ca.gov
1 /7n/1Nl'] 'I.AC nrA
,I ..F A
irefox
about:blank
DocuSign Envelope ID: 51 B94C71 -AD75-4C56-8BCD-24FO534BA4AA
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
l -D
Lucia Martel Dora for San Rafael School Board 2022
Type of Committee Kondnuedl
General Purpose Committee 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
List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS
NO. AND STREET CITY
Small Contributor Committee m
Date quallfied
OR AFRUATION OF 5PONSOR
STATE zip CODE
Termination Requirements By signing the Verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent cern y that aii o
• 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.
- d for political, legislative or governmental purposes under Government Code Sections 89511- 89518, and are
Leftover funds of ballot measure committees may be use
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
1 Nr%Nl n'17 11.AC T11
7 _F A