HomeMy WebLinkAboutForm 410- Lucia Martel Dow for San Rafael School Board 2022; Termination (State) 03-10-23Firefox
Docu Sign Envelope ID: 511394C71-AD75-4C56-8BCD-24FO534BA4AA
Statement of Organization
Recipient Committee
Statement Type ❑ Initial
RECEIVED AND FUE"D
in the office of the Secretary of State
of the State of California
DateStamp
JAN 3 1 2023
Amendment IQ Termination -see Part 5
Q Not yet qualified
or
Q Date qualification threshold met I Date qualification threshold met Date of termination
11 07 30 / 2022 12 / 31 , 2022
1. Committee Information I.D. Number 2. Treasurer and Other Principal Officers
(ifapplicable) 1442869
NAME OF COMMITTEE NAME OF TREASURER OFF)
Lucia Martel DoviT for San Rafael School Hoard 2022 Lucia Martel Dei•;
Sne ETAODRESS (NO P.O. Box)
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
CITY STATE ZIP CODE AREACODE/PHONE
Novato CA 94949-5731 (
FULL MAILING ADDRESS (IF DIFFERENT)
COUNTY OF DOMICILE l JURISDICTION WHERE COMMITTEE IS
Marin County I San Rafael
Attach additional information on appropriately labeled continuation sheets.
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CE
Novato
CA 94945-5731 (
NAME OF ASSISTANT TREASURER, IF ANY
Nancy L Warren
STREerADDRESS NO P.O. BOX)
CITY
STATE ZIPCODE AREA CODE/PHONE
Novato
CA 94949-5731 (
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O BOX)
CITY STATE ZIP CODE AREA CODE/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
Executed on
netflle. com
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, ORSTATE MEASURE PROPONENT
FPPC Form 410 (August/2018)
FPPC Advice: advice Lmfppc. ca.gov (866[275-3772)
www.fppc.ca.gov
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DocuSign Envelope ID: 51B94C71-AD75-4C56-813CD-24F0534BA4AA
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Lucia Martel Do% for San Rafael School Board 2022
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
Bank of San Francisco
AREA CODE/PHONE
(415)744-63700
CITY
STATE VP CODE
NUMBER
2 of 3
1442569
ADDRESS
575 Market Street X900
San Francisco CA Mlo:
4. iylae of Comm+tfee complete the applicable sections.
• 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
Nonpartisan I Pa an (list POIF ai party
Lucia Martel Do;.* School Board City of San Rafael 2022 X
Primarily Formed committee Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATES) NAME OR MEASU REIS) FULL TITLE (INCLUDE BALLOT NO, OR LETTER)
IP n RFCAI I . STATE "RECALL IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATE(S) OFFICESOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY. AS APPLICABLE)
OPPOSE
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FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
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DocuSign Envelope ID: 51B94C71-AD75-4C56-8BCD-24F0534BA4AA
Statement of organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Lucia Martel Dora for San Rafael School Board 2022
4. Type of Committee JL0ntutue0J
General Purpose Committee I Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ Cot1NTy Committee ❑ STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponscis on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
Small Contributor Committee
CITY
GROUP OR AFFILIATION OF SPONSOR
SFAIC -1-1
Page 3 of 3
5, Termination Requirements By signing the veriftcation,the treasurer. assistant tfeasurerand/or candidate, officeholder. or proponent certify that all of the following conditions have been mer.
• 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
Cade 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
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