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Home My WebLink AboutForm 410 - Police Association PAC Amend 02-12-25Statement of Organization Recipient Committee Statement Type ❑ Initial ❑ Amendment Q Not yet qualified or O Date qualification threshold met Date qualification threshold met 01 / 01 / 1983 I.D. Number (ijopplicable) 831553 NAME OF COMMITTEE San Rafael Police Association Political Action Committee at am ❑ Termination — !§A�6rt 5 L 20,"'- STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE San Rafael CA 94901 ( FULL MAILING ADDRESS (IF DIFFERENT) San Rafael, CA 94915-1557 E-MAIL ADDRESS OF COMMITTEE (REQUIRED) / FAX (OPTIONAL) COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE Marin County, CA Attach additional information on appropriately labeled continuation sheets Date of terminItion i CITY CLERK'S OFFICE / NAME OF TREASURER Marissa Carney STREET ADDRESS (NO P.O. BOX) CITY San Rafael EMAIL ADDRESS OF TREASURER (REQUIRED) NAME OF ASSISTANT TREASURER, IF ANY Stacy E. Owens STREET ADDRESS (NO P.O. BOX) CITY Oakland EMAIL ADDRESS OF ASSISTANT TREASURER (REQUIRED) NAME OF PRINCIPAL OFFICER(S) Christopher Fuller, Vice President STREET ADDRESS (NO P.O. BOX) CITY San Rafael EMAIL ADDRESS OF PRINCIPAL OFFICER(S) (REQUIRED) For Official Use Only STATE ZIP CODE CA 94901 AREA CODE/PHONE ( STATE ZIP CODE CA 94607 AREA CODE/PHONE ( STATE ZIP CODE CA 94901 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 PROPONENT Executed on DATE Executed on By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (October/2023) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov neff►le-com Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME San Rafael Police Association Political Action Committee NAME POSITION Michael Mathis, President Principal Officer STREET ADDRESS (NO P.O. BOX) CITY STATEZIP CODE San Rafael CA 94901 E-MAIL ADDRESS AREA CODE/PHONE ( HE Page 2 of 4 831553 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 COMMITTEE NAME San Rafael Police Association Political Action Committee Page 3 of 4 I.D. NUMBER 831553 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 US Bank (415)448-0145 Marissa Carney, Michael Mathis ADDRESS OF FINANCIAL INSTITUTION CITY STATE ZIP CODE 369 3rd 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 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) 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 OPPOSE SUPPORT OPPOSE FPPC Form 410 (October/2023) FPPC Advice: advice@fppc.ca.eov (866/275-3772) www.fppc.ca.aov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Page 4 of 4 COMMITTEE NAME I.D. NUMBER San Rafael Police Association Political Action Committee 831553 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 To make political contributions to support and oppose candidates and issues of interest to the San Rafael Police Association. List additional sponsors on an attachment. NAME OF SPONSOR San Rafael Police Association STREET ADDRESS NO. AND STREET ❑ INDUSTRY GROUP OR AFFILIATION OF SPONSOR Union CITY STATE ZIP CODE AREA CODE/PHONE San Rafael CA 94901 ( Date qualified 5. 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