HomeMy WebLinkAboutForm 410 - Police Association PAC Amend 01-24-20Statement of Organization E 0a aMd IC-ALIFORNIA '
Recipient Committee •
Statement Type ❑ Initial E Amendment ❑ Termination — See Pa For Official Use Only
Q Not yet qualified `� I I 1) n x'70
or
O Date qualification threshold met Date qualification threshold met Date of termination CITY CLERK'S OFFIC
/ / O1 / 01 1983
. Committee Information I.D. Number (if applicable) 831553 2. Treasurer and Other Principal Officers'
_ �..
NAME OF COMMITTEE
San Rafael Police Association Political Action Committee
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 (REQUIRED) / FAX (OPTIONAL)
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
Marin County, CA
Attach additional information on appropriately labeled continuation sheets.
3ert cation
I have used all reasonable diligence in preparing this statement and to the best f my k
penalty of perjury under the laws of the State of California that the f g ' i r n
Executed on 1/9/2020 By
ATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
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 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
netfile. com
Statement of Organization
Recipient Committee
UAL11-SA1,13A
41 U
FORM
ON REVERSE
Page 2 of 4
COMMITTEE NAME
I.D. NUMBER
831553
San Rafael Police Association Political Action Committee
2a. Additional Officers/ Assistant Treasurers
NAME
NAME
Zachary Brickell, President
MAILING ADDRESS
MAILING ADDRESS
CITY STATE ZIP CODE
AREACODE/PHONE
CITY
STATE
ZIPCODE AREACODE/PHONE
San Rafael CA 94901
(
NAME
NAME
MAILING ADDRESS
MAILING ADDRESS
CITY
STATE
ZIPCODE AREACODE/PHONE
CITY STATE ZIP CODE
AREACODE/PHONE
NAME
NAME
MAILING ADDRESS
MAILING ADDRESS
AREA CODE/PHONE
CITY
STATE
ZIP CODE AREA CODE/PHONE
CITY STATE ZIP CODE
NAME
NAME
MAILING ADDRESS
MAILING ADDRESS
CITY
STATE
ZIPCODE AREA CODE/PHONE
CITY STATE ZIP CODE
AREA CODE/PHONE
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAMEI I.D. NUMBER
San Rafael Police Association Political Action Committee 831553
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
Union Bank
ADDRESS
AREA CODE/PHONE
(
CITY
BANK ACCOUNT NUMBER
STATE ZIP CODE
3 of 4
San Rafael CA 94901
.T�
4: Tyke of Comrnl. ee complete the'papplicable sections.
• 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
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)
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
T OPPOSE
OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 4 of 4
COMMITTEE NAME I i.u. rvumnen
San Rafael Police Association Political Action Committee
4. Type of
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑x 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.
NAMEOFSPONSOR
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 (
t�7i iTd l [S•]ii �i7arK•7i[4.1i ilii 1►K�:�
❑ /
Date qualified
5 Termination Re uirement5. Bysigningthevgrificatiori,thetreasurer•assistanttreasurerand/orcandidate,officeholder, or proponent cei#ifythat all ofthefo(Iowingcandiriansha�eheentnet: °'
• 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 maybe 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 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov