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Home My WebLink AboutForm 460- Maribeth Bushey-Lang for City Council 2013 (2013-09-21) AmendmentRecipient Committee Campaign Statement CoverPage (Government Code Sections 84200-84216.1 Type or print in ink. Statement covers period from 7/1/13 SEE INSTRUCTIONS ON REVERSE through 9/21/13 ---- --------- 1. Ty pe of Reci pient Com m iftee: All Committees - Complete Parts I j 21 3, and 4. Officeholder, Candidate Controlled Committee E] Primarily Formed Ballot Measure 0 State Candidate Election Committee Committee 0 Recall 0 Controlled (Also Complete Part 5) 0 Sponsored Providing additional/corrected info (Also Complete Part 6) E] General Purpose Committee 0 Sponsored Primarily Formed Candidate/ 0 Small Contributor Committee Officeholder Committee 0 Political Party/Central Committee (Also Complete Part 7) 0 A. 3. Committee InformatIon COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) Maribeth Bushey Lang for San Rafael City Council 2013 STREET ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE San Rafael CA 94901 ( MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL: FAX/ E-MAIL ADDRESS Date of election if applicable:. (Month, Day, Year) t 11/5/13 Page 1 of 5 For Official Use Only 2. Type of Statement: El Preelection Statement El Quarterly Statement E] Semi-annual Statement E] Special Odd -Year Report Termination Statement Supplemental Preelection (Also file a Form 410 Termination) Statement - Attach Form 495 Amendment (Explain below) Providing additional/corrected info on 6 monetary contributors; add I omission; correct additioncarryover to pp. 3, 4 NAME OF TREASURER Mark Kyle MAILING ADDRESS CITY San Rafael STATE CA ZIP CODE 94901 AREA CODE/PHONE ( NAME OF ASSISTANT TREASURER, IF ANY ® We, CPA Jamait MAILING ADDRESS CITY San Rafael STATE CA ZIP CODE 94901 AREA CODE/PHONE ( OPTIONAL: FAX / E-MAIL ADDRESS Executed on Date Executed on Date 11� PUMP Signalure of Controlling Officeholder, Candidate, State Measure Proponent Ofgesponsible Officer of SponsW BY Signature of Controlling Officefidder, Canddate, State Measure Proponent BY Signature of Contoffing Officehoider, Candata, State Measure Proponent FP PC Form 460 (January106) FPPC Toll -Free Helpline: 8661ASK-FPPC (8661276-3772) State of California ejM;fAj: . 4 Alk CALIFORNIA 0. FORM 460 6. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Maribeth Bushey Lang OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) City Council, City of San Rafael RESIDENTIAUBUSI NESS ADDRESS (NO. AND STREET) CITY STATE ZIP San Rafael, CA 94901 Related Committees Not Included in this Statement: List any committees 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 I.D.NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? E] YES 0 NO COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE COMMITTEE NAME I.D.NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? I [:] YES E] NO COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE 2 5 Page Of 6. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE BALLOT NO. OR LETTER JURISDICTION [:]SUPPORT [] OPPOSE Identify the controlling officeholder, candidate, or state measure proponent, if any. NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT OFFICE SOUGHT OR HELD I 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 E] SUPPORT [30PPOSE 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 Fonn 460 (January/05) FPPC Toll -Free Helpline.- 866/ASK-FPPC (8661276-3772) State of Callforrila Campaign Disclosure Statement Summary Page Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period from , 7/1/13 SEE INSTRUCTIONS ON REVERSE through 9/21/13 Page 3 Of 5 NAME OF FILER I.D.NUMBER Maribeth Bushey Lang for San Rafael City Council 2013 358370 Contributions Received Column Column B Calendar Year Summary for Candidates TOTALTHIS PERIOD (FROM ATTACHED SCHEDULES) CALENDAR YEAR TOTAL TO DATE Running •in Both the State Primary and General Elections 1. Monetary Contributions ........................................... Schedule A, Line 3 $ 18 ,430 , $ 21 130 2. Loans Received ...................................................... Schedule B, Line 3 0 0 1/1 through 6/30 7/1 to Date 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines I + 2 $ 18,430 $ 21,130 20. Contributions 4. Nonmonetary Contributions .................................... Schedule C, Line 3 3 j579 4, 579 Received $ $ 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED .......................... Add Lines 3 + 4 $ 22,009 $ 25,709 Made $ $ Expenditures Made Expenditure Limit Summary for State 6. Payments Made ....................................................... Schedule E, Line 4 $ 8,231 $ 5,281 Candidates 7. Loans Made ............................................................. Schedule H, Line 3 —0 0 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6 + 7 $ 612 11 $ 61281 22. Cumulative Expenditures Made* (if Subject to Voluntary Expenditure Limit) 9. Accrued Expenses (Unpaid Bills) ............................... Schedule F, Line 3 8,954 8,954 Date of Election Total to Date 10. Nonmonetary Adjustment .......................................... Schedule Q, Line 3 3,579 41579 (mm/dd/yy) 11. TOTAL EXPENDITURES MADE ................................ Add Lines 8 + 9 + 10 $ 18,764 $ 19,814 $ Current Cash Statement $ 12. Beginning Cash Balance ....................... Previous Summary Page, Line 16 $ 2,550 To calculate Column B, add 13. Cash Receipts ................................................... Column A, Line 3 above 18,430 amounts in Column A to the 14. Miscellaneous Increases to Cash ........................... Schedule 1, Line 4 0 corresponding amounts from Column B of your last *Amounts in this section may be different from amounts reported in Column B. 15. Cash Payments .................................................. Column A, Line 8 above 8,231 report. Some amounts in Column A may be negative 16. ENDING CASH BALANCE .......... Add Lines 12 + 13 + 14, then subtract Line 15 $ 14,849 figures that should be subtracted from previous If this is a termination statement, Line 16 must be zero. period amounts. If this is the first report being filed 17. LOAN GUARANTEES RECEIVED .......................... Schedule B, Part 2 $ 0 for this calendar year, only carry over the amounts Cash Equivalents and Outstanding Debts from Lines 2, 7, and 9 (if 0 any. 18. Cash Equivalents ...... ................................. See instructions on reverse $ 19. Outstanding Debts ......................... Add Line 2 + Line 9 in Column B above $ 8,954 FPPC Form 460 (January/06) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661276-3772) Schedule A Type or print in ink. SCHEDULE A Amounts may oe rounaea Monetary Contributions Received to whole dollars. Statement covers period CALIFORNIA from 7/1/13 , • ' . Page 4 of 5 SEE INSTRUCTIONS ON REVERSE through 9/21/13 NAME OF FILER I.D. NUMBER Maribeth Bushey Lang for San Rafael City Council 2013 358370 DATE FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR (E COMMITTEE, ALSOAND ZIP I.D. NUMBER) CONTRIBUTOR IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER AMOUNT RECEIVED THIS CUMULATIVE TO DATE CALENDAR YEAR PER ELECTION TO DATE RECEIVED CODE * (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. 1 - DEC. 31) (IF REQUIRED) OF BUSINESS) ® IND 7/29/13 lijklWONM ❑COM retired 100 100 corrected address ❑OTH Alamo, CA 94507 E] PTY + occupation info; p ❑SCC on page 6 ®IND 8/6/13 EICOM retired 300 300 corrected address 10na*ae ❑ OTH 4 01 ❑ PTY + occupation info; ❑ SCC on page 9 ❑IND Beale Street Parking, LLC ❑COM 8/13/13 ®OTH 500 500 corrected address ❑ PTY information; on ❑ SCC page 9 ®IND 8/9/13 L nn Carew []COM retired 250 250 corrected address E] OTH 1 ❑ PTY + occupation info; ❑ SCC on page 10 Mark Polite ®IND ❑COM Partner, 8/21/13 ❑OTH Seagate Properties 500 500 corrected Mill Valley, CA 94941 [:]occu PTY occupation info; p ❑ SCC on page 11 SUBTOTAL$ N/A Schedule A Summary Amount received this period — itemized monetary contributions. (Include all Schedule A subtotals.) ............................................ 2. Amount received this period — unitemized monetary contributions of less than $100 3. Total monetary contributions received this period. (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1.) ...... TOTAL $ 17,050 1,380 18,430 "Contributor Codes IND—Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY — Political Party SCC — Small Contributor Committee FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) Schedule A (Continuation Sheet) Type or print in ink. SCHEDULE A (CONT.) Monetary Contributions Received Amounts may be rounded Statement covers period • . to whole dollars. 7/1/13 ' from • 9/21/13 5 5 through Page of NAME OF FILER I.D. NUMBER Maribeth Bushey Lang for San Rafael City Council 2013 358370 DATE FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER AMOUNT RECEIVED THIS CUMULATIVE TO DATE CALENDAR YEAR PER ELECTION TO DATE RECEIVED (EFTA COMMITTEE, ALSO ENTER IDNUMBER) I.D. CODE * (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. 1 -DEC. 31) (IF REQUIRED) OF BUSINESS) ®IND ❑COM Scientist, 9/17/13 Wva, ❑OTH Genentech 250 250 Page 12 -corrected F-1 PTY occupation ❑ SCC information 8/1/13 Jeffrey Schoppert ®IND [3Com Attorney, 250 250 Page 13 - addition; ❑OTH Keegin, Harlison, originally omitted San Rafael, CA 94903 F-1PTYSchoppert + Karner LLP ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC SUBTOTAL$ N/A `Contributor Codes IND—Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY — Political Party SCC — Small Contributor Committee FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)