HomeMy WebLinkAboutForm 410 - Maribeth Bushey for City Council D3 2022 (termination)Statement of Organization
Recipient Committee
Statement Type ❑ initial ❑ Amendment
0 Not yet qualified
or
0 Date qualification threshold met Date qualification threshold met
I . Number 1452093
MOM
(Ifoppllcable)
7Re-Elect
EE
ribeth Bushey San Rafael City Council District 3 2022
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREACODE/PHONE
San Rafael CA 94901
FULL MAILING ADDRESS (IF DIFFERENT)
E-MAIL ADDRESS OF COMMITTEE (REQUIRED) / FAX (OPTIONAL)
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
Marro I City of San Rafael
Attach additional information on appropriately labeled continuation sheets.
-
® Termination —See Part �� A 1 4 2026 For Official Use Only t, ;;
Date of termination CITY CLERK'S 0 F F I E
0--1 14 / 2026
NAME OF TREASURER
Mark L. Kyle
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODI
San Rafael CA 94901
EMAIL ADDRESS OF TREASURER (REQUIRED) AREA CODE/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE
EMAIL ADDRESS OF ASSISTANT TREASURER (REQUIRED) AREA CODE/PHONE
PAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE
EMAIL ADDRESS OF PRINCIPAL OFFICER(S) (REQUIRED) 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
7Ao--)z
Executed onBy
ATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE,O MEASURE PROPONENT
Executed on
DATE
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING CF FICEHOLDER, CANDIDATE. OR STATE MEASURE PROPONENT
FPPC Farm 410 (October/2023)
FPPC Advice: advice@fppc.ca.eov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Pago 2
COMMITTEE NAME I.D NUMBER
Re -Elect Maribeth Bushey San Rafael City Council District 3 2022 11452093
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
Bank of Maria 1415-485-2275 12969373
ADDRESS OF FINANCIAL INSTITUTION 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
if
Partisan
ilist political party below)
Nonpartisan
Partisan
(IISt political party below)
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATES) 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 (October/2023)
FPPC Advice: advice 0fnnc.ca.sov (866/275-3772)
www.foac.ca.gov
Statement of Organization
Recipient Committee W4,
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAM I.D. NUMBE
Re -Elect Maribeth Bushey San Rafael City Council District 3 2022 11452093
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
❑ �-1 1
❑ COUNTY Committee ❑ STATE Committee
CITY
GROUP OR AFFILIATION OF SPONSOR
STATE ZIP CODE AREA CODE/PHONE
J. Termination Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or ponent certify that all ofthe 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: adviceQMfPPc.ca.eov (866/275-3772)
www.fpac.ca.eov