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Form 410 - Yes on Measure E 2013 TerminationEatement of Organization Recipient Committee Statement Type n Initial Not yet qualified El or I --- / Date qualified as committee M F1 Amendme List I.D. number I I Date qualified as committee (if applicable) 0 Termination —See Part List I.D. number: # 1359556 1 12 1 20 1, 13 Date of Termination 1. Committee Information 2. Treasu*rer and Other Principal Officers NAME OF COMMITTEE NAME OF TREASURER Committee For A Safer San Rafael - Yes On Measure E Jeffrey S. Schoppert STREETADDRESS (NO P.O. BOX) STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE San Rafael CA 94901 CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY San Rafael CA 94901 Will LaBranche MAILING ADDRESS (IF DIFFERENT) STREETADDRESS (NO P.O. BOX) OPTIONAL: FAX/ E-MAILADDRESS CITY STATE ZIP CODE AREA CODE/PHONE San Rafael CA 94901 NAME OF PRINCIPAL OFFICER(S) COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT Gary Phillips THAN COUNTY OF DOMICILE Marin STREETADDRESS (NO P.O. BOX) Attach additional information on appropriately labeled continuation sheets. CITY STATE ZIP CODE AREA CODE/PHONE San Rafael CA 94901 3. Verification I have used all reasonable diligence in preparing this statement and to the best of knowledge the info ation ontained 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 torr t. C Executed on December 20, 2013 By DATE TIGNATURE 5PfTRtASUR 6fr0R_A_T1SSISANT TREASURER Executed on By DATE SIGNATURE OF CONTROLLING OFFICE -HOLDER, CANDIDATE, OR STATE MEASURE PROPONENT Executed onDATE BY SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT Executed on y B DATE SIC TUBE F COITR O.LING 7 F-710EHOLDER, CANDIDATE, 0R'S7A_TEMEASURE PROPONENTT FPPC Form 410 (June/09) FPPC Toll -Free Helpline: 8661ASK-FPPC (8661275-3772) a Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE %aINIM-411i " R^C111 Committee For A Safer San Rafael - Yes On Measure E 4. Type of Committee Complete the applicable sections. W11wilky4rs1 1359556 • 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 "non-partisan." ® If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. NAME OF CAN DIDATE/OFFICEHOLDER/STATE MEASURE PROPONENTELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY, likIFI&T WM bW1TK_A_-U�rTFi TF =79 STATE ZIP CODE F_ 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 (INCLUDE DISTRICT NO., CITY OR COUNP� AS APPLICABLE) City Transactions and Use Measure - Measure E W L X_* M" *I Allllllllllllll SUPPORT x momr`! i FPPC Form 410 (June/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) R Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Page 3 COMMITTEE NAME I.D. NUMBER Committee For A Safer San Rafael - Yes On Measure E 1359556 4. Type of Committee (Continued) C am ULM Not formed to support or oppose specific candidates or measures in a single election. Check only one box: EI CITY Committee COUNTY Committee STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY 'Sponsored Committee List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREETADDRESS NO. AND STREET CITY STATE ZIP CODE TIME Date qualified 5.Terminat"li t By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent 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. Defer 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 - 95 , and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5. FPPC Form 410 (June/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)