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Form 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