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Form 410 - Carolina Martin for San Rafael School Board Trustee 2022 (State)Date -Statement of Organization / 1 Iq 3 � • ' t� Recipient Committeeoa Statement Type 0Initial ElAmendment ElTermination — See Part 5 Ino State of Calild is For Official Use Only ® Not yet qualifiedJUN or 2 4 2022 O Date qualification threshold met Date qualification threshold met Date of termination JUI "'022 LD. Number 1.®mmittee 0nformation 2. Treasurer and Other Principal Officers (if applicable) s NAME OF COMMITTEE NAME OF TREASURER Carolina Martin for San Rafael City Schools District 4 2022 Chelsea Johnson STREET ADDRESS (NO P.O. BOX) STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE Antelope CA 95843 ( CITY STATE ZIP CODE AREA CODE/PHONE NAM E OF ASSISTANT TREASURER, IF ANY Antelope CA 95843 ( FULL MAILING ADDRESS (IF DIFFERENT) STREET ADDRESS (NO P.O. BOX) E-MAIL ADDRESS(REQUIRED)/FAX(OPTIONAL) CITY STATE ZIP CODE AREA CODE/PHONE COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(S) Marin City of San Rafael STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE Attach additional information on appropriately labeled continuation sheets. 3. Verification 1 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 under the laws of the State of 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 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Carolina Martin for San Rafael City Schools District 4 2022 e All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION First Foundation Bank ADDRESS AREA CODE/PHONE (916)724-2424 CITY BANK ACCOUNT NUMBER STATE ZIP CODE 2233 Douglas Blvd., Ste. 300 Roseville CA 95661 4. Type of Cor�em'itee Complete the' applicable sections. I.D. NUMBER Paae 2 of 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. a 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 Carolina Martin Board of Education City of San Rafael District 4 2022 Nonpartisan X Partisan (list political party below) Nonpartisan Partisan (list political party below) 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 ON E T OPPOSE OPPOSE FPPC Form 410 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement ®f Organization Recipient Committee INSTRUCTIONS ON REVERSE Page 3 of 4 MMITTEE NAME I I.D. NUMBER Carolina Martin for San Rafael City Schools District 4 2022 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 STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE ❑ .1 /, Date qualified 5. Termination Reiquir0'm6ritS By+signing the verification, the treasurer, assistant treasurer and/or candldate;'officeholderi or proponent certify that all of the fallowing contlitions have been met: ®This committee has ceased to receive contributions and make expenditures; ® This committee does not anticipate receiving contributions or making expenditurees 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 ADDITIONAL COMMENTS For Form 410 Page 4 of 4 COMMITTEE NAME I.D. NUMBER Carolina Martin for San Rafael City Schools District 4 2022 Additional Mailing Address: San Rafael, CA 94901 www.netfile.com