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Form 410 - Maika Llorens Gulati for City Council 2020Statement of Organization Recipient Committee Statement Type 10 initial Amendment 10 Termination —See Not yet qualified or Date qualification threshold met I Date qualification threshold met Date of termination 1 F E 9 - 5 2020 CLERK'S For official use only I.D. Number 1. Comrrmhtee InformiMon. Z. treasurer and Ot11 #ier Princi�al kers (if applicable) NAME OF COMMITTEE NAME OF TREASURER Maika Llorens Gulati for San Rafael City Council District 1 2020 Maika Llorens Gulati STREET ADDRESS (NO P.O. BOX) STREET ADDRESS (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 FULL MAILING ADDRESS (IF DIFFERENT) E MAILADDRESS (REQUIRED) / FAX (OPTIONAL) COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE 15 ACTIVE Marin City of San Rafael Attach additional information on appropriately labeled continuation sheets. STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE NAME OF PRINCIPAL OFFICER(S) Maika Llorens Gulati STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA COD E/PHONE San Rafael CA 94901 3. Ve c on .. 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 unfler the laws of the State of California that the foregoi rue and rrect. Executed on � C� � By OAT 1 2 Executed on /7 Z� By DATE GNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT Executed on I By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT Executed on DATE By 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 Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Page 2 COMMITTEE NAME I.D. NUMBER Maika Llorens Gulati for San Rafael City Council District 1 2020 • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER Redwood Credit Union 1800-479-7928 111000000641127 ADDRESS CITY STATE ZIP CODE 209 Third Street San Rafael CA 94901 4. TNpe pf Cctnmil!iPd Ciomplel�e the a�`plfcable.seWtins. 4 • 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 IFAPPLICABLE) ELECTION CHECK ONE • Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATES) NAME OR MEASURE(S) FULLTITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATES) OFFICE SOUGHT OR HELD OR MEASURES) JURISDICTION IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE FPPC Form 410 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Nonpartisan Partisan (list political party below) Maika Llorens Gulati San Rafael City Council District 1 2020 Nonpartisan Partisan (list political party below) • Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATES) NAME OR MEASURE(S) FULLTITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATES) OFFICE SOUGHT OR HELD OR MEASURES) JURISDICTION IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE 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 Maika Llorens Gulati for San Rafael City Council District 1 2020 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 List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR Page 3 STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA COD E/PHONE ❑ —/ 1 Date quallfled 5th _erit lhation 111"uirem6nts ayslgningt"e, edjlaation,thutreasumr, assistant treasvrerand/orcandidate, ofllceho}dei•, orpmponentcertify'Aatall ofthefolloWngcon.ditionshave 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 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