HomeMy WebLinkAboutForm 460 - Maribeth Bushey for City Council 2017 (2016-06-30)Recipient Committee
Campaign Statement
Cover Page
SEE INSTRUCTIONS ON REVERSE
Statement covers period
from ____ 1_1_1/_1_6 __ _
6/30/16 through ________ _
Date of election if aplplic:at"~
(Month, Day, Year)
"'~1111
COVER PAGE
1. Type of Recipient Committee: All Committees -Complete Parts 1, 2, 3, and 4. 2. Type of Statement:
o Preelection Statement
bZl Semi-annual Statement
3.
I!lI Officeholder, Candidate Controlled Committee o State Candidate Election Committee o Recall
(Also Complet. Pet! 5)
o General Purpose Committee o Sponsored o Small Contributor Committee o Political Party/Central Committee
ST.!3;7 ET ADDRESS (NO P.O. BOX)
;)
o Primarily Formed Ballot Measure
Committee o Controlled o Sponsored
(Also COmplet. Pet! 6)
o Primarily Formed Candidatel
Officeholder Committee
(Also COmplet. Pet! 7)
I.D. NUMBER
o Termination Statement
(Also file a Form 410 Termination)
o Amendment (Explain below)
Treasurer(s)
NAME OF TREASURER
MAILING ADDRESS
CITY
AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
' -
MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE CITY
OPTIONAL: FAX I E·MAILADDRESS OPTIONAL: FAX I E-MAIL ADDRESS
o Quarterly Statement o Special Odd-Year Report
STATE ZIP CODE AREA CODE/PHONE
STATE ZIP CODE AREA CODE/PHONE
4. Verification
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 .
certify under penalty of perjury under the laws of the State of California that the foregoing is true and correc\.
Executed on 8/1/16
Date
Executed on 8/1/16
Date
Executed on
Date
Executed on
Date
By ____________ ~----~~~~~~~~~~~~-----------------
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BY----------~S~ig~n~mU~~~O~f~Co~n~tr~~II~ng~O~ffi~I~~h~OI~de~~~Ca~n~~~da~te~.S~ta~te~M~e~as~ur~e~Pr~o~~ne~n~t-----------
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Recipient Committee
Campaign Statement
Cover Page -Part 2
5_ Officeholder or Candidate Controlled Committee
NUMBER IF APPLICABLE)
San Rafael City Councilmember
RESIDENTIAUBUSINES~RESS (NO. AND STREET) CITY 62;.#. ZIP
, ~-'-~cJ4-
Related Committees Not Included in this Statement: List any com ~~ () I
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.
COMMITIEE NAME J.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITIEE?
DYES D NO
COMMITIEE ADDRESS STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
COMMITIEE NAME J.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITIEE?
DYES D NO
COMMITIEE ADDRESS STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
COVER PAGE -PART 2
--"II'-!JI!II!I!IIIIIIJII
6. Primarily Formed Ballot Measure Committee
NAME OF BALLOT MEASURE
BALLOT NO. OR LETIER JURISDICTION D SUPPORT
D OPPOSE
Identify the controlling officeholder, candidate, or state measure proponent, if any.
NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT
OFFICE SOUGHT OR 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
D SUPPORT
D OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
D SUPPORT
D OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
D SUPPORT
D OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
D SUPPORT
D OPPOSE
Attach continuation sheets if necessary
FPPC form 460 (Jan/20i6)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Campaign Disclosure Statement
Summary Page
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
Contributions Received
1. Monetary Contributions ................................................... Schedule A. Une 3 $
2. Loans Received ................................................................ ScheduleS, Une3
3 . SUBTOTAL CASH CONTRIBUTIONS .............................. Add Unes 1 + 2 $
4. Nonmonetary Contributions............................................ Schedule C, Une 3
5. TOTAL CONTRIBUTIONS RECEIVED .................................... Add Unes 3 + 4 $
Expenditures Made
6 . Payments Made................................................................ Schedule E, Une 4 $
7. Loans Made....................................................................... Schedule H, Une 3
8. SUBTOTAL CASH PAyMENTS .......................................... Add Unes 6 + 7 $
9. Accrued Expenses (Unpaid Bills) .......................................... Schedule F, Une 3
10. Nonmonetary Adjustment... ...................................................... Schedule C, Une 3
11. TOTAL EXPENDITURES MAD E. ....................................... Add Unes B + 9 + 10 $
Current Cash Statement
12. Beginning Cash Balance ............................ Previous Summary Page, Une 16 $
13. Cash Receipts ........................................................... Column A, Une 3 above
14. Miscellaneous Increases to Cash .................................. Schedule I, Une 4
15. Cash Payments ......................................................... Column A, Une B above
16 . ENDING CASH BALANCE .................. Add Unes 12 + 13 + 14. then subtract Une 15 $
If this is a termination statement, Line 16 must be zero.
17. LOAN GUARANTEES RECEiVED ................................ ScheduleS, Part 2 $
Cash Equivalents and Outstanding Debts
18. Cash Equivalents ................................................ See instructions on reverse $
19. Outstanding Debts .............................. Add Une 2 + Une 9 in Column S above $
Amounts may be rounded
to whole dollars.
ColumnA
TOTAL THIS PERIOD
(FROM ATTACHED SCHEDULES)
o
o
v
()
o
SUMMARY PAGE
Statement covers period CALIFORNIA 460
FORM from ____ 1_/1_/1_6 __ _
3 3 6/30/16 through ________ _ Page ___ of __ _
$
$
$
$
$
$
Column B
CALENDAR YEAR
TOTAL TO DATE
Q
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
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 Limit)
Date of Election
(mmldd/yy)
Total to Date
$-----
----.1-----1__ $ ____ _
"Amounts in this section may be different from amounts
reported in Column B.
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
