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Form 461- Friends of the SR Public Library (2016-06-30)Major Donor and Independent Expenditure Committee Campaign Statement SEE INSTRUCTIONS ON REVERSE 1. Name and Address Statement covers period from 01/01/2016 through 06/30/2016 NAME OF FILER FRIENDS OF THE SAN RAFAEL PUBLIC LIBRARY SAN RAFAEL (If filer is other than an individual) PHYLLIS BRINCKERHOFF CA 94901 AREA CODE/DAYTIME PHONE . Nature and Interests of Filer (Complete each applicable section.) A FILER WHO IS AN INDIVIDUAL MUST LIST THE NAME, ADDRESS, AND BUSINESS INTERESTS OF EMPLOYER OR, IF SELF-EMPLOYED, THE NAME, ADDRESS, AND NATURE OF THE BUSINESS NAME OF EMPLOYER/BUSINESS I BUSINESS INTERESTS A FILER THAT IS A BUSINESS ENTITY MUST DESCRIBE THE BUSINESS ACTIVITY IN WHICH IT IS ENGAGED E] A FILER THAT IS AN ASSOCIATION MUST PROVIDE A SPECIFIC DESCRIPTION OF ITS INTERESTS ® A FILER THAT IS NOTAN INDIVIDUAL, BUSINESS ENTITY, OR ASSOCIATION MUST DESCRIBE THE COMMON ECONOMIC INTEREST OF THE GROUP OR ENTITY ASSIST THE SAN RAFAEL PUBLIC LIBRARY IN SERVING THE ENTIRE ❑ Amendment (Explain): COMMUNITY 0 MAY 2 0 2016 Date of election if applicable: (Month, Day, Year) age 1 of 2 06/07/2016 CITY CLERK'S OF ICE F rOfficial use only 3. Summary (Amounts may be rounded to whole dollars.) 1. Expenditures and contributions (including loans) of $100 or more 15,000.00 made this period. (Part 5.) ................................................ $ 2. Unitemized expenditures and contributions (including loans) under $100 made this period ...................................................... $ 3. Total expenditures and contributions 15,000.00 made this period. (Add Lines 1 + 2.)................SUBTOTAL $ 4. Total expenditures and contributions made from prior statement. (Enter amount from Line 5 of last statement filed. If this is the first statement for the calendar year, enter zero.) ......................................... $ 5. Total expenditures and contributions (including loans) made since January 1 of the current calendar year. 15,000.00 (Add Lines 3 +4.)...................................................TOTAL $ 4. Verification I have used all reasonable diligence in preparing this statement. I have reviewed the 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 California that the foregoing is true and correct. Executed on 05/20/2016 DATE B Y SIGNATU OF INDIVIDUAL DONOR OR RESPONSIBLE OFFTCER. IF OTHER THAN AN INDIVIDUAL FPPC Forth 461 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Major Donor and Independent Expenditure Committee Amounts may of rounded p p to whole dollars. Campaign Statement SEE INSTRUCTIONS ON REVERSE FRIENDS OF THE SAN RAFAEL PUBLIC LIBRARY Statement covers period from 01/01/2016 through 06/30/2016 5. Contributions (Including Loans, Forgiveness of Loans, and Loan Guarantees) and Expenditures Made (if more space is needed, use additional copies of this page for continuation sheets.) 2 Page—....__.. of FPPC Forth 461 (Jan/2016) FPPCAdvice: advicea@fppc.ca.gov (866/276-3772) www.fppc.ca.gov DESCRIPTION OF CANDIDATE AND OFFICE, CUMULATIVE AMOUNT DATE NAME, STREET ADDRESS, CITY, STATE AND ZIP CODE TYPE OF PAYMENT PAYMENT MEASURE AND JURISDICTION, AMOUNTTHIS RELATED TO THIS OF PAYEE (IF OTHER THAN MONETARY OR COMMITTEE PERIOD CANDIDATE, MEASURE, (IF COMMITTEE, ALSO ENTER I.D. NUMBER) CONTRIBUTION OR LOAN) OR COMMITTEE COMMITTEE TO SUPPORT SAN RAFAEL ® Monetary MEASURE D LIBRARIES Contribution 1000 FOURTH STREET, SUITE 600 ❑ Loan 15,000.00 15,000.00 3/23/2016 SAN RAFAEL, CA 94901 ❑ Non -Monetary Contribution FPPC I.D. NUMBER: 1383895 ❑ Independent Expenditure ® Support ❑ Oppose ❑ Monetary Contribution ❑ Loan ❑ Non -Monetary Contribution ❑ Independent Expenditure ❑ Support ❑ Oppose ❑ Monetary Contribution ❑ Loan ❑ Non -Monetary Contribution ❑ Independent Expenditure ❑ Support ❑ Oppose ❑ Monetary Contribution ❑ Loan ❑ Non -Monetary Contribution ❑ Independent Expenditure ❑ Support ❑ Oppose SUBTOTAL $ 15,000.00 FPPC Forth 461 (Jan/2016) FPPCAdvice: advicea@fppc.ca.gov (866/276-3772) www.fppc.ca.gov