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Home My WebLink AboutForm 410 - Carolina Martin for San Rafael School Board Trustee 2022; Termination (State)Statement of Organization Recipient Committee Statement Type ❑ Initial ® Amendment O Not yet qualified or 0 Date qualification threshold met Date qualification threshold met / 07 / 29 / 2022 M-1 a I 1 "40 a I.D. Number (if applicable) 1449397 NAME OF COMMITTEE Carolina Martin for San Rafael City Schools District 4 2022 ® Termination — See Part 5 STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE Lakeport CA 95453 ( FULL MAILING ADDRESS (IF DIFFERENT) E-MAIL ADDRESS OF COMMITTEE (REQUIRED)/ FAX (OPTIONAL) COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE Marin I City of San Rafael Attach additional information on appropriately labeled continuation sheets. Date of termination 09 / 30 / 2024 NAME OF TREASURER Chelsea Johnson Date Stamp DIGITALLY RECEIVED AND FI in the office of the Calif Secretary of State OCT 04 2024 STREET ADDRESS (NO P.O. BOX) EMAIL ADDRESS OF TREASURER (REQUIRED) NAME OF ASSISTANT TREASURER, IF ANY STREET ADDRESS (NO P.O. BOX) EMAIL ADDRESS OF ASSISTANT TREASURER (REQUIRED) NAME OF PRINCIPAL OFFIC STREET ADDRESS (NO P.O. BOX EMAIL ADDRESS OF PRINCIPAL OFFICER(S) (REQUIRED) CITY Lakeport CITY CITY 9 20, STATE ZIP CODE CA 95453 AREA CODE/PHONE ( STATE ZIP CODE AREA CODE/PHONE STATE ZIP CODE AREA CODE/PHONE 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. 10/03/2024 Executed on By DATE SIGNATURE OF TREASURER OR ASSISTANT TREASURER 10/03/2024 ZIOGI!? li N!N Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT Executed on DATE Executed on DATE netfle.com By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (October/2023) FPPC Advice: advice0fooc.ca.eov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Carolina Martin for San Rafael City Schools District 4 2022 Page 2 of 4 I.D. NUMBER 1449397 All committees must list the financial institution where the campaign bank account is located and the person(s) authorized to obtain bank records. NAME OF FINANCIAL INSTITUTION AND PERSON(S) AUTHORIZED TO OBTAIN BANK RECORDS AREA CODE/PHONE BANK ACCOUNT NUMBER First Foundation Bank (916)724-2424 ADDRESS OF FINANCIAL INSTITUTION CITY STATE ZIP CODE 2233 Douglas Blvd., Ste. 300 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 Carolina Martin Board of Education City of San Rafael District 4 2022 Nonpartisan X 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) 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) CHECKONE" FPPC form 410{6etober/2023),, FPPC Advice: adviceCbDfopc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Carolina Martin for San Rafael City Schools District 4 2022 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 INDUSTRY GROUP OR AFFILIATION OF SPONSOR Page 3 of 4 I.D. NUMBER 1449397 STATE ZIP CODE AREA CODE/PHONE S. Termination Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or ponent 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 may be 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 (October/2023) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fPPC.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Carolina Martin for San Rafael City Schools District 4 2022 Additional Mailing Address: San Rafael, CA 94901 Page 4 of 4 I.D. NUMBER 1449397 FPPC Form 410 (October/2023) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov