HomeMy WebLinkAboutForm 460 - Paramedic Services PAC (2011-12-31)Recipient CommftWe
Campaign Statement
Cover Page
(Government Code Sections 84200-84216.5)
SEE INSTRUCTIONS ON REVERSE
Type or print in Ink.
Statement covers period ' Date of election if appal
from 7/1/11 (Month, Day, Year)
through
12/31/11
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
O Recall
O Controlled
(Also Complete Part 5)
O Sponsored
® General Purpose Committee
(AW Complete Part 6)
Q Sponsored
❑ Primarily Formed Candidate/
Q Small Contributor Committee
Officeholder Committee
Q Political Party/Central Committee
(Also Complete Part 7)
3. Committee Information
IlDuPP�?
Committee for San Rafael Paramedic Services
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
San Rafael CA 94903 (
MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX
CITY STATE ZIP CODE AREA CODE/PHONE
• •ADDRESS
I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information contained herein and in the attached schedules is true and complete. i certify
under penalty of perjury under the taws of tf a State of California that the foregoing is true and correct.
Executed on j / wBy
otTressufor orAssistantTrassiger
Executed on By Si 4reofC-er,C .Staff Messure ProponentorResponsbie OffioerofSpomr
Executed on By
Date SWwhre ofCorftlftori , State Messuv Proponent
Executed on By
Date SofComrofffv Oftehokler, Carddate, state Measure Proponent FPPC Fort 460 (January/05)
FPPC Toil -Free Helpline: 866/ASK-FPPC (5881278-3772)
State of California
Type or print In Ink. COVER PAGE - PART c
Recipient Committee CALIFORNIA
Campaign Statement.. ' • 1
Cover Page — Part 2
Page of 3
6. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHOLDER OR CANDIDATE NAME OF BALLOT MEASURE
OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) BALLOT NO. OR LETTER ' JURISDICTION
RESIDENTIAUBUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP
Related Committees Not Included in this Statement; L/sranycommittees
not Included in this statement that are controlled by you or are primarily formed to receive
contributions or make expenditures on behalf of your candidacy.
COMMITTEE NAME
NAME OF TREASURERI CONTROLLED COMMITTEE?
❑ YES ❑ NO
CITY STATE ZIP CODE AREA CODE/PHONE
•
NAME OF TREASURER
COMMITTEE•D- •r- • P.O. c•
CITY STATE ZIP CODE •• • -
Identify the controlling officeholder, candidate, or state measure proponent, if any.
NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT
HELD
DISTRICT NO. IF ANY
7. Primarily Formed Candidate/Officeholder Committee List names of
officeholder(s) or candidate(s) for which this committee Is primarily formed.
NAME OF OFFICEHOLDER OR CANDIDATE
OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE
OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE
OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE
OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
Attach continuation sheets if necessary
FPPC Form 460(January/06)
FPPC Toil -Free Helpline. 6661ASK-FPPC (6661276-3772)
State of California
Campaign Disclosure Statement
Summary Page
Type or print In ink.
Amounts may be rounded
to whole dollars.
Statement covers period
from 7/1/11
SUMMARY
Expenditures Made
$
6. Payments Made .......................................................
Schedule E, Line 4 $
through
12/31/11
Page. 3 of 3
SEE INSTRUCTIONS ON REVERSE
9. Accrued Expenses (Unpaid Bills) ..................... — .......
Schedule F Une 3
10, Nonmonetary Adjustment ..........................................
Schedule C, Line 3
11. TOTAL EXPENDITURES MADE ................................Add
Lines 8 + 9 + 10 $
NAME OF FILER
0
$
0
I.D.NUMBER
Committee for San Rafael Paramedic Services
983147
Column A
Column B
Calendar Year Summary for Candidates
Contributions Received
TOTALTHISPER100
CALENDAR YEAR
TOTALTO DOWE
Running in Both the State Primary and
(FROMATTACHEDSCHMULES)
General Elections
1. Monetary Contributions ...........................................
Schedule A, Line 3
$ 0 $
— 102.00
0
0
1/1 through 6130 7/1 to Date
2, Loans Received......................................................
Schedule B, Line 3
3. SUBTOTAL CASH CONTRIBUTIONS .........................
Add Lines 1 +2
$ 0$
102.00
20, Contributions
Received $ $
—
4. Nonmonetary Contributions ....................................
Schedule C, Line 3
21, Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED ..........................
• Add Lines 3 + 4
$ 0 $
102.00,
Made $ $
Expenditures Made
$
6. Payments Made .......................................................
Schedule E, Line 4 $
7. Loans Made .............................................................
Schedule H, Line 3
8. SUBTOTAL CASH PAYMENTS ....................................
Add Unes 8 + 7 $
9. Accrued Expenses (Unpaid Bills) ..................... — .......
Schedule F Une 3
10, Nonmonetary Adjustment ..........................................
Schedule C, Line 3
11. TOTAL EXPENDITURES MADE ................................Add
Lines 8 + 9 + 10 $
0
$
0
0
0
0
$
0
0
0
0
0
0
$
0
Current Cash Statement
12. Beginning Cash Balance.............. ........ Previous Summary Page, Line 16 $ 5,328.04
13. Cash Receipts ... ....... ...................... .... --- .... Column A, Line 3 above 0
14. Miscellaneous Increases to Cash ........................... Schedule 1, Line 4 0
15. Cash Payments ..... .............. — ................... ....... Column A, Line 8 above — 0
16. ENDING CASH BALANCE .......... Add Lines 12 + 13 + 14, then subtract Line 15 $ 5,328.04
If this Is a termination statement, Line 16 must be zero.
17. LOAN GUARANTEES RECEIVED ..... .......... -- ..... Schedule 8, Part 2 $ 0
Cash Equivalents and Outstanding Debts
18. Cash Equivalents ........................................ See instructions on reverse $ 0
19. Outstanding Debts ......................... Add Line 2 +Line gin Column B above $ 0
To calculate Column B, add
amounts In Column A to the
corresponding amounts
from Column B of your last
report. Some amounts In
Column 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).
Expenditure Limit Summary for State
Candidates
22. Cumulative Expenditures Made*
IN Subject to voluntary Expenditure Lin*)
Date of Election Total to Date
(mm/dd/yy)
Anel $
*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 (866/275-3772)