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Home My WebLink AboutForm 460 - Paramedic Services PAC (2016-12-31)Recipient Committee Campaign Statement Cover Page SEE INSTRUCTIONS ON REVERSE Statement covers period from ____ 7_/1 _/1_6 __ _ 12131/16 through ________ _ 1. Type of Recipient Committee: A" Committees -Complete Parts 1, 2, 3, and 4. 3. o Officeholder, Candidate Controlled Committee o Primarily Formed Ballot Measure Committee o State Candidate Election Committee o Recall (Abo Complete Pil1I 5) !ill General Purpose Committee o Sponsored ® Small Contributor Committee o Political Party/Central Committee o Controlled o Sponsored (Mc Complele Pall 6) o Primarily Formed Candidatel Officeholder Committee (A,.c Comp'.'. Pall 7) Committee for San Rafael Paramedic Services STREET ADDRESS (NO P.O. BOX) San Rafael STATE ZIP CODE CA 94903 MAILING ADDRESS <IF DIFFERENn NO. AND STREET OR P.O. BOX CITY STATE ZIP CODE OPTIONAL: FAX I E-MAIL ADDRESS AREA CODEIPHONE AREACODEIPHONE 4. Verification Stamp 1 0 201 Date of election If appllc:allilel (Month, Day, Year) CITY CLERK'S 0 2. Type of Statement: o Preelection Statement III Semi-annual Statement o Termination Statement (Also file a Form 410 Termination) o Amendment (Explain below) Treasurer(s) NAME OF TREASURER Greg Knell MAILING ADDRESS same CITY NAME OF ASSISTANT TREASURER , IF A/oN MAILING ADDRESS CITY OPTIONAL: FAX I E-MAIL ADDRESS o Quarterly Statement o Special Odd-Year Report STATE ZIP CODE AREA CODEIPHONE STATE ZIP CODE AREA CODEIPHONE I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge th certify under penalty of perju und the laws of the State of California that the foregoing is true and correct. he In and in the attached schedules is true and complete. I Executed on ___ '+""""'-1::=1_"--___ _ Executed on -----""O:-;,al~e------ Executed on -----""D'"'.I,..,.e------ Executed on ------::O,..,at,..,.e------ By-""S=,gn~a~lu=~=Of~c~on~lr~OIl~in~gO~m~~~h~cl~,~c=aoo~1=~~le~.S~ta~~~M~e=a.~u~~P~ro=p~on~e=nt7.or~R~e.~po~n~.ib~le~O~ffi~~~r=of~S~~n.~~~ By ________ ~~~~==~~~~~~~~~~~~~--------Signature of Controlling OfflC8holder, Candidate, State Measure Proponent By-----------::S~ig~na~tu~~~o~rc,..,on~tro~I~lin~gO~ffi~lC8~h~ot~d.-"~C~an~dl~da~te~,S~ta~ta~M~.~as~ur-e~Pro~p~o~~nt---------- FPPC Form 460 (Jan/lOI6) FPPC Advice: advice@fppc.ca_gov (866/Z7S-317l) WWW.fppC.C8_gov Campaign Disclosure Statement Summary Page SEE INSTRUCTIONS ON REVERSE NAME OF FILER Contributions Received 1. Monetary Contributions................................................... Schedule A, Line 3 2 . Loans Received ................................................................ Schedule B. Line 3 $ 3. SUBTOTAL CASH 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................................................................ Schedule E. Line 4 $ 7. Loans Made ....................................................................... ScheduleH. Line 3 8 . SUBTOTAL CASH PAYMENTS .......................................... Add Lines 6 + 7 $ 9 . Accrued Expenses (Unpaid Bills) .......................................... Schedule F. Line 3 10 . Nonmonetary Adjustment... ...................................................... Schedule C. Line 3 11 . TOTAL EXPENDITURES MADE. ....................................... 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 I. 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. 17 . LOAN GUARANTEES RECEIVED ................................ Schedule B. Part 2 $ Cash Equivalents and Outstanding Debts 18. Cash Equivalents ................................................ See instructions on reverse $ Amounts may be rounded to whole dollars. ColumnA TOTAL THIS PERIOD (FROM ATTACHED SCHEDULES) 50.00 50.00 50.00 5247.62 7.52 50.00 5204.52 o o 19. Outstanding Debts .............................. Add Line 2 + Line 9 in Column B above $ o SUMMARY PAGE Statement covers period CALIFORNIA 460 FORM 7/1/16 from ________ _ 2 4 12/31/16 through _______ _ Page ___ of __ _ $ $ $ $ $ $ Column B CALENDAR YEAR TOTAL TO DATE o o o o o 50.00 50 .00 50.00 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). 1.0 . NUMBER 1075199 Calendar Year Summary for Candidates Running in Both the State Primary and General Elections 1/1 through 6/30 7/1 to Date 20. Contributions Received $ ____ _ $----- 21 . Expenditures Made $ ____ _ $----- Expenditure Limit Summary for State Candidates 22. CumulatIve Expenditures Made' (If Subject to Voluntary Expenditure Llmltl Date of Election (mm/dd/yy) --.l~ __ Total to Date $----- $----- "Amounts in this section may be different from amounts reported in Column B . FPPC Form 460 (Jan/ZOI6) FPPC Advice: advice@fppc.ca.gov (866/Z75-3772) www.fppc.ca.gov Schedule A Monetary Contributions Received SEE INSTRUCTIONS ON REVERSE NAME OF FILER Committee for San Rafael Paramedic Services Amounts may be rounded to whole dollars. DATE RECEIVED FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR (IF COMMITTEE. ALSO ENTER 1.0 . NUMBER) CODE * IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (IF SELF·EMPLOYED. ENTER NAME OF BUSINESS) Schedule A Summary 1. Amount received this period -itemized monetary contributions. OIND o COM DOTH OPTY OSCC OIND o COM DOTH OPTY Osec OIND OCOM DOTH OPTY Osce OIND OCOM DOTH OPTY OSCC OIND o COM DOTH OPTY OSCC SUBTOTAL $ SCHEDULE A Statement covers period from ____ 7/_1_/1_6 __ _ CALIFORNIA 460 FORM h h 12/31/16 t roug _______ _ Page __ 3_ Of __ 4_ AMOUNT RECEIVED THIS PERIOD LD.NUMBER CUMULATIVE TO DATE CALENDAR YEAR (JAN. 1 • DEC . 31) PER ELECTION TO DATE (IF REQUIRED) ·Contributor Codes IND -Individual (Include all Schedule A subtotals .) ......................................................................................................... $ _____ _ COM -Recipient Committee (other than PTY or SCC) OTH -Other (e.g., business entity) PTY -Political Party 2. Amount received this period -unitemized monetary contributions of less than $100 ........................... $ _____ 7_._5_2 3. Total monetary contributions received this period. (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1.) ...................... TOTAL $ _____ 7._5_2 SCC -Small Contributor Committee FPPC Form 460 (Jan/2016) FPPC Advice: advice@fppt.ca.gov (866/275-3772) www.fppc.ca.gov SCHEDULE E Schedule E Payments Made Amounts may be rounded to whole dollars. Statement covers period from ___ 7_'1_'_16 __ _ CALIFORNIA 460 FORM SEE INSTRUCTIONS ON REVERSE through __ 1_2_'_3_1/_1_6 __ Page _4 __ of _4 __ NAME OF FILER 1.0 . NUMBER Committee for San Rafael Paramedic Services CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CMP campaign paraphemalia/m isc . MBR member communications RAD radio airtime and production costs CNS campaign consultants MTG meetings and appearances RFD retumed contributions CTB contribution (explain nonmonetary), OFC office expenses SAL campaign workers' salaries cve civic donations PET petition circulating TEL t.v. or cable airtime and production costs FIL candidate filing/ballot fees PHO phone banks TRC candidate travel, lodging , and meals FND fund raising events POL polling and survey research TRS staff/spouse travel, lodging , and meals IND independent expenditure supporting/opposing others (explain)' POS postage, delivery and messenger services TSF transfer between committees of the same candidate/sponsor LEG legal defense PRO professional services (legal, accounting) VOT voter registration LIT campaign literature and mailings PRT print ads WEB information technology costs (intemet, e-mail) NAME AND ADDRESS OF PAYEE (IF COMM ITIEE, ALSO ENTER 1.0. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID California Secretary of State Annual Political Reform fee FIL 50.00 * Payments that are contributions or independent expenditures must also be summarized on Schedule D . SUBTOTAL $ 50.00 Schedule E Summary 50.00 1. Itemized payments made this period. (Include all Schedule E subtotals.) ............................................................................................................. $ _____ _ 2. Unitemized payments made this period of under $100 .......................................................................................................................................... $ _____ _ 3. Total interest paid this period on loans . (Enter amount from Schedule 8, Part 1, Column (e).) ............................................................................. $ _____ _ 50.00 4. Total payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.) ........................... TOTAL $ _____ _ FPPC Form 460 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov