HomeMy WebLinkAboutForm 410 - Carolina Martin for San Rafael School Board Trustee 2022; AmendmentStatement of Organization
Recipient Committee
Statement Type rL initial 10 Amendment
I Not yet qualified
or
O Date qualification threshold met Date qualification threshold met
/ /
I. Committee Information I.D. Number
(if applicable) IHl•t 3161_7
NAME OF COMMITTEE
Carolina Martin for San Rafael City Schools District 4 2022
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
0
❑ Termination —See NU �1 SEP - 2 2022
Antelope CA 95843 (
FULL MAILING ADDRESS (IF DIFFERENT)
E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL)
COUNTY OF DOMIOLE I JURISDICTION WHERE COMMITTEE 15 ACTIVE
Marin
City of San Rafael
Attach additional information on appropriately labeled continuation sheets.
Date of terminatio C1 CLERK'S OFFICE
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Chelsea Johnson
STREET ADDRESS (NO RO BOX)
For Official Use Only
CITY STATE ZIP CODE AREA CODE/PHONE
Antelope CA 95843• (
NAME OFASSISTANT TREASURER, IF ANY
STREETADDRESS(NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
C'TY STATE ZIP CODE AREA CODE/PHONE
3. verification
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 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
netfde.com
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Carolina Martin for San Rafael City Schools District 4 2022
• 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 Committee Complete the applicabie sections.
I -D NUMBER
2 of 4
1449397
• 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.
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT
Carolina Martin
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE)
Board of Education City of San Rafael
District 4
YEAR OF PARTY
ELECTION CIIECKONE
Nonpartisan I Partisan Iiist political party
2022 1 X
Nonpartisan i Partisan lliist political party
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) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT OPPOSE
OPPOS,
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 3 of 4
COMMITTEE NAME I D. NUMBER
Carolina Martin for San Rafael City Schools District 4 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 ACTIVI IY
List additional sponsors on an attachment.
NAME OF SPONSOR 1,11111 •STRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE
!T 1:71[IIeTi77il i]liUlYt
11
Date qualified
S. Termination, Requirements By signing the verification, th'e treasurer, assistant treasurer and/or candidate, officeholder, or proponent terrify 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
Additional Comments
For Form 410
COMMITTEE NAME
Carolina Martin for San Rafael City Schools District 4 2022
Additional Mailing Address: San Rafael, CA 94901
www.netfile.com
COMMENTS
Page 4 of 4
.D. NUMBER
1449397