HomeMy WebLinkAboutForm 460 - Paramedic Services PAC (2015-06-30)Recipient Committee
Campaign Statement
Cover Page
(Government Code Sections 84200-84216.5)
SEE INSTRUCTIONS ON REVERSE
Type or print in Ink.
Statement covers period
from
through P13B/�-s
1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4.
❑ Officeholder, Candidate Controlled Committee Primarily Formed Ballot Measure
Q State Candidate Election Committee Committee
Q Recall JgControlled
(Also Complete Part 5) O Sponsored
(Also complete Part 6)
❑ General Purpose Committee
Q Sponsored ❑ Primarily Formed Candidate/
Q Small Contributor Committee Officeholder Committee
Q Political Party/Central Committee (Also Complete Part 7)
3. Committee Information ID NUMBER
NAME (OR CANDIDATE'S NAME IF NO COMMITTEE)
STREET ADDRESS (NO P 0. BOX)
'
CITY STATE ZIP CODE AREA CODE/PHONE
MAILING ADDRESS (IF DIFFERENT) NO AND STREET OR PO. BOX
CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX/ E-MAIL ADDRESS
Date of election If applicable:
(Month, Day, Year)
COVER PAGE
ate Stam • - 461
as . •-
0 205 Page T_ of Z
For Official Use Only
t Ime:
city Clerk's O:fi e
,:tit of San Rafael
2. Type of Statement:
❑ Preelection Statement ❑ Quarterly Statement
�$. Semi-annual Statement ❑ Special Odd -Year Report
❑ Termination Statement ❑ Supplemental Preelection
(Also file a Form 410 Termination) Statement - Attach Form 495
❑ Amendment (Explain below)
Treasurer(s)
NAME OF TREASURER
kii e4z_
MAILING ADDRESS
J. LA E
CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX / E-MAIL ADDRESS
4. Verification
I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the infor on
under penalty of peq' un er the laws of the State of California that the foregoing is true and correc
Z�i�Executed on By
ate Signature at " reasurer
and in the attached schedules Is true and complete I certify
Executed on By / /
Date Signature of Control) OPoceholderCandidate, StateMeasure Proponent orResponsible Officer ofSponsor
Executed on By
Date Signature of Controlling Officeholder, Candidate, State Measure Proponent
Executed on By Signature of Controttrtg OMcenoider, Candidate, State Measure Proponent Date FPPC Forth 460 (Januaryl06)
FPPC Toll -Free Helpline: 866/ASK-FPPC (6661275-3772)
State of California
Campaign Disclosure Statement Type or print in ink.
Amounts may be rounded
Summary Page to whole dollars.
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
Contributions Received
1 Monetary Contributions . . ................. .... Schedule A, Line 3
2. Loans Received .. .... Schedule e, Line 3
3. SUBTOTALCASH CONTRIBUTIONS .... Add Lines 1 +2
4. Nonmonetary Contributions ....................... Schedule c, Line 3
5. TOTAL CONTRIBUTIONS RECEIVED .. •••• Add Lines 3+4
Expenditures Made
6. Payments Made ...........................
7. Loans Made ................ .............
8 SUBTOTAL CASH PAYMENTS .....
9. Accrued Expenses (Unpaid Bills)
10. Nonmonetary Adjustment ............
11. TOTAL EXPENDITURES MADE ....
Schedule E, Line 4
Schedule H, Line 3
Add Lines 6 + 7
Schedule F, Line 3
Schedule C, Line 3
...... ..... .. Add Lines 8 + 9 + 10
Current Cash Statement
12. Beginning Cash Balance .......... Previous summary Page, Line 16
13 Cash Receipts .. .. column A, Line 3 above
14. Miscellaneous Increases to Cash Schedule 1, Line 4
15 Cash Payments Column A, Line 8 above
16 ENDING CASH BALANCE .......... Add lines 12 + 13 + 14 then subtract Line 15
If this is a termination statement, Line 16 must be zero.
$
U
i
Column A
TOTALTHIS PERIOD
(FROM ATTACHED SCHEDULES
_15
Statement covers period
from
�i /2
through
Column B
CALENDARYEAR
TOTALTO DATE
$ 119-
16—
$
$
17 LOAN GUARANTEES RECEIVED Schedule B, Part 2 $
Cash Equivalents and Outstanding Debts
18. Cash Equivalents ............. ..... . ........ See instructions on reverse $
19. Outstanding Debts ...... . ... Add Line 2 + Line 9 in Column B above S
t1culate Column B, add
amounts in Column A to the
corresponding amounts
from Column B of your last
Ceport. Some amounts in
olumn A may be negative
figures that should be
subtracted from previous
period amounts. If this is
the first report being filed
for this calendar year, only
carry over the amounts
from Lines 2, 7, and 9 (if
any).
PAGE
Page 2 of 2.
I D. NUMBER
Calendar Year Summary for Candidates
Running in Both the State Primary and
General Elections
111 through 6/30 711 to Date
20. Contributions
Received S $
21. Expenditures
Made $ $
Expenditure Limit Summary for State
Candidates
22. Cumulative Expenditures Made*
III'Subtect to Voluntary Expenditure Llmlt)
Date of Election Total to Date
(mm/dd/yy)
'Amounts in this section may be different from amounts
reported in Column B.
FPPC Form 460 (January/05)
FPPC Toll -Free Helpline: 866/ASK-FPPC (86612753772)