HomeMy WebLinkAboutForm 410- Maribeth Bushey for City Council 2017 AmendmentStatement of Organization
Recipient Committee
Statement Type o Initial
Not yet qualified 0 or
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Date qualified as committee
1. Co Information
NAME OF COMMlnEE
I2J Amendment
list 1.0. number:
# 1358370
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Date qualified as committee
Ilf applicable)
Maribeth Bushey for San Rafael City Council 2017
STREET ADDRESS INO P.O. BOX)
D Termination -5ee Part 5
list 1.0. number:
#_-------
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Date ofTermination
2. Treasurer and --
NAME OF TREASURER
Mark Kyle, Esq.
STREET ADDRESS (NO P.O. BOX)
CITY
San Rafael
Date Stamp
2 5 2016
AND o~cfhee or the Secretary of
o St3fe of California
A~R 13 2016
CITY CLERK'S OFFIC
rs
STATE ZIP CODE AREA CODE/PHONE
CA 94901 (
CIT Y STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY
San Rafael ca 94901 (
MAILING ADDRESS (IF DIFFERENT) STREET ADDRESS INO P.O. BOX)
FAX / E-MAIL ADDRESS CITY
COUNTY OF DOMICILE JURISDICTION WHERE CDMMlnEE IS ACTIVE NAME OF PRINCIPAL OFFICERIS)
Marin City of San Rafael
STREET ADDRESSINO P.O . BOX)
CITY
Attach additional information on appropriately labeled continuation sheets.
Executed on By
Executed on By
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
STATE ZIP CODE AREA CODE/PHONE
STATE ZIP CODE AREA CODE/PHONE
FPPC Form 410 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov