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Form 410- Lucia Martel Dow for San Rafael School Board 2022; AmendmentStatement of Organizationp US W iRe�mlf CALIFORNIA i Recipient Committee Statement Type ❑ initial Q Amendment ❑ Termination — See AUG 2 5 2022 For Officlal Use Only Q Not yet qualified ij or O Date qualification threshold met Date qualification threshold met Date of termination CITY CLERK'S OFFICE / ' 1 30 / 2022 1. Committee Information I.D. Number 1442869 2. Treasurer and Other Principal Officers (if applicable) NAME Of TREASURER NAME OF COMMITTEE Lucia Martel Dow for San Rafael School Board 2022 Lucia Martel Dow STREET ADDRESS (NO P.O. BOX) STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE Novato CA 94949-5731 ( FULL MAILING ADDRESS (IF DIFFERENT) E-MAIL ADDRESS (REQUIRED)/ FAX (OPTIONAL] COUNTY OF DOMICILE I JURISDICTION WHERE COMMITTEE IS ACTIVE Marin County I San Rafael Attach additional information on appropriately labeled continuation sheets. Novato CA 94949-5731 ( NAME OF ASSISTANT TREASURER, IF ANY Nancy L Warren RESS (NO STREET ADDP.O. BOX} CITY STATE ZwCOO E AREA CODE/PHONE Novato CA 94949-5731 ( NAME OF PRINCIPALOFFICERiS) STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE 3. Verification I have used all reasonable diligence In preparing Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, ORSTATE MEASURE PROPONENT FPPC Form 410 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov --ars]....-- Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Lucia Martel Dow for San Rafael School Board 2022 • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION Bank of San Francisco ADDRESS AREA LODE/PHONE (415)744-6700 CITY BANK ACCOUNT NUMBER STATE ZIP CODE 575 Market Street #900 San Francisco CA 94105 4. Type of Committee Complete the applicable sections. I.D. NUMBER 2 of 3 1442869 o 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. o List the political party with which each officeholder or candidate is affiliated or check "nonpartisan.' Stating "No party preference" is acceptable. o 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 Lucia Martel Dow School Board City of San Rafael 2022 Nonpartisan X Partisan (list political party below) Nonpartisan Partisan (list political party below) Primarily Formed Committee 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) CHECKONE T I 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 0 1 H INSTRUCTIONS ON REVERSE Page 3 of 3 I.D. NUMSER COMMS TTEF. NAME Lucia Martel Dow for San Rafael School Board 2022 4. Type of Committee (Continued) 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 STREET ADDRESS NO -AND STREET CITY INDUSTRY GROUP OR AFFILIATION OF SPONSOR STATE CIM LUM �+rtcr Date quallfled S. 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 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov