HomeMy WebLinkAboutForm 410 - Police Association PAC Amend 01-28-13Statement of Organization
Recipient Committee
Statement Type ❑ Initial El Amendment
Not yet qualified ❑ or List I.D. number:
# 831553
01/01/1983
Date qualified as committee Date qualified as committee
(If applicable)
1. Committee Information
NAME OF COMMITTEE
San Rafael Police Association Political Action Committee
STREET ADDRESS (NO P.O. BOX)
Date Stamp
❑ Termination — See Part 5 For official Use Only
List I.D. number:
Date of Termination
CITY STATE ZIP CODE AREA CODE/PHONE
San Rafael, CA 94901 (415) 485-3000
MAILING ADDRESS (IF DIFFERENT)
P.O. Box 151557
San Rafael, CA 94915-1557
FAX / E-MAIL ADDRESS
COUNTY OF DOMICILEI JURISDICTION WHERE COMMITTEE IS ACTIVE
Marin County, CA
Attach additional information on appropriately labeled continuation sheets.
2. Treasurer and
NAME OF TREASURER
Ms. Beth Minka
STREET ADDRESS (NO P.O. BOX)
CITY
San Rafael, CA 94901
STATE ZIP CODE AREA CODE/PHONE
(415) 485-3000
NAME OF ASSISTANT TREASURER, IF ANY
Ms. Stacy E. Owens
STREET ADDRESS (NO P.O. BOX)
CITY
Oakland, CA 94618
STATE ZIP CODE AREA CODE/PHONE
(510) 652-1000
NAME OF PRINCIPAL OFFICER(S)
Mr. Carl Huber, President
STREET ADDRESS (NO P.O. BOX)
CITY
San Rafael, CA 94901
STATE ZIP CODE AREA CODE/PHONE
(415) 485-3000
3. Verification
I have used all reasonable diligence in preparing this tatement and to the best of my knowledge the information contained herein is true and complete. 1 certify under
penalty of perjury under the laws of the State of CafWi
It'A rof i true and correct.
Executed on 01/28/2013 By _
DATE SIGNATURE OF TREASUREWOJ, ASSISTANT TREASURER
Executed on 01/28/2013 By
DATE _. L4
SIGNATURE OF CONTROLLIN ICEHOLDER. CANDIDATE. OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410(Dec/2012)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
bIAItMtNI OF UHUANIZAIIUN
Recipient Committee
CALIFORNIA
410
FORM
INSTRUCTIONS ON REVERSE
2 of 5
COMMITTEE NAME
I.D. NUMBER
San Rafael Police Association Political Action Committee
831553
2a. Additional Officers
NAME OF OTHER PRINCIPAL OFFICER(S)
NAME OF OTHER PRINCIPAL OFFICER(S)
Mr. Kyle Hornstein, Vice President
MAILING ADDRESS
MAILING ADDRESS
CITY STATE
ZIP CODE
AREA CODEIP-HONE
CITY
STATE
ZIP CODE
AREACODE/PHONE
San Rafael, CA 94901
(415) 485-3000
NAME OF OTHER PRINCIPAL OFFICER(S)
NAME OF OTHER PRINCIPAL OFFICER(S)
MAILING ADDRESS
MAILING ADDRESS
CITY STATE
ZIP CODE
AREA CODE/PHONE
CITY
STATE
ZIP CODE
AREA CODE/PHONE
NAME OF OTHER PRINCIPAL OFFICER(S)
NAME OF OTHER PRINCIPAL OFFICER(S)
MAILING ADDRESS
MAILING ADDRESS
CITY STATE
ZIP CODE
AREACODE/FH-ONE
CITY
STATE
ZIP CODE
AREA CODE/PHONE
NAME OF OTHER PRINCIPAL OFFICER(S)
NAME OF OTHER PRINCIPAL OFFICER(S)
MAILING ADDRESS
MAILING ADDRESS
CITY STATE
ZIP CODE
AREA CODE/FH-ONE
CITY
STATE
ZIP CODE
AREACODE/PHONE
FPPC Form 410 (June/09)
www.netfile.com FPPC Toll -Free Helpline: 8661ASK-FPPC
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
San Rafael Police Association Political Action Committee
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
Union Bank 4152592727 0110141303
ADDRESS
1248 Fifth Avenue
4. Type of Committee Complete the applicable sections.
CITY
San Rafael
STATE ZIP CODE
CA 94901
Page 2 of 5
I.D. NUMBER
831553
• 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."
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CAN MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION
PARTY
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 COUNTY, AS APPLICABLE)
CHECK ONE
FPPC Form 410 (Dec/2012)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
SUPPORT
OPPOSE
SUPPORT
Orl
FPPC Form 410 (Dec/2012)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization (91
Recipient Committee •
INSTRUCTIONS ON REVERSE
Page 3 of 5
COMMITTEE NAME I.D. NUMBER
San Rafael Police Association Political Action Committee 831553
4. Type of Committee (Continued)
General Purpose Committee 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
.. List additional sponsors on an attachment.
NAME OF SPONSOR
San Rafael Police Association
Union
GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE
1520 Fifth Avenue
San Rafael CA 94901
Smoll Contributor Committee
Date qualified
5. Termination Requirements 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. 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 (Dec/2012)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Additional Comments
for Form 410
INSTRUCTIONS ON REVERSE
San Rafael Police Association Political Action Committee
Committee has changed officers.
1019
5 of 5
D. NUMBER
831553
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