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Home My WebLink AboutForm 460 - Maribeth Bushey for City Council 2017 (2017-06-30)Recipient Committee Campaign Statement Cover Page Statement covers period from ___ J_a_nu_a_ry-=--.1-,-, _2_0_17_ SEE INSTRUCTIONS ON REVERSE June 30, 2017 through ________ _ 1. Type of Recipient Committee: All Committees -Complele 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 (Also Campl.18 Parl5) o General Purpose Committee o Sponsored o Smail Contributor Committee o Political Party/Central Committee o Controlled o Sponsored (Also Cample18 Pal16) o Primarily Formed Candidate/ Officeholder Committee (Also Complete Perl7) Marlbeth Bushey for San Rafael City Council l.D\ 7 STREET ADDRESS (NO P.O. BOX) 396 Riviera Dr CITY San Rafael STATE ZIP CODE CA 94901 MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX CITY STATE ZIP CODE OPTIONAL: FAX I E-MAIL ADDRESS AREA CODEJPHONE 415.455.0115 AREA CODEJPHONE 4. Verification I have used ail reasonable diligence in preparing and reviewing this statement and to the best of certify under penalty of perj ry under he laws of the State of California that the foregoing is true Executed on -_'~f-'7-'--"10d-:"""'-'----Oae Executed on 'Z L a () I 17 lite Date of election if applicable: (Month, Day, Year) November 7,2017 2. Type of Statement: o Preelection Statement I;zJ Semi-annual Statement o Termination Statement (Also file a Form 410 Termination) o Amendment (Explain below) Treasurer(s) NAME OF TREASURER Mark Kyle MAILING ADDRESS 25 Cottonwood CITY San Rafael NAME OF ASSISTANT TREASURER. IF ANY MAILING ADDRESS CITY OPTIONAL: FAX I E-MAIL ADDRESS JUl 31 o Quarterly Statement o Special Odd-Year Report STATE ZIP CODE CA 94901 STATE ZIP CODE AREA CODE/PHONE 415.246.2025 AREA CODEJPHONE . n contained herein and in the attached schedules is true and complete. I Executed on -----.... O""o-:-te-------By-------~S~ig~n~aW~m~O~f~co~n~tm~lIi~ng~Offi~~~h~OI~d.~~~c~an~di~da~t.~.S~m~te~M~e~os~u~m~P~ro~~~oo~n~t----------- Executed on -----'O-=a:::te-------By------~S~19M~tum~Of~c~on~~~"'~ng~o~ffi~IOO~h~Old~e~~~~nd~Id~ot~e.~Sm~t~e~Me~o~.u~m~P~ro~~~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 NAME OF OFFICEHOLDER OR CANDIDATE Maribeth Bushey OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) San Rafael City Council RESIDENTIAUBUSINESS ADDRESS (NO . AND STREET) CI1Y STATE ZIP 1400 Fifth Ave San Rafael, CA 94901 Related Committees Not Included In this Statement: Llstanycommlttees not Included In this statement that are controlled by you or are primarily formed to receive contrlbuUons or make expenditures on behalf of your candidacy. COMMITIEE NAME I.D .NUMBER NAME OF TREASURER CONTROLLED COMMITIEE? DYES DNO COMMITIEE ADDRESS STREET ADDRESS (NO P.O. BOX) CI1Y STATE ZIP CODE AREA CODE/PHONE COMMITTEE NAME I.D . NUMBER NAME OF TREASURER CONTROLLED COMMITIEE? DYES o NO COMMITIEE ADDRESS STREET ADDRESS (NO P.O. BOX) CI1Y STATE ZIP CODE AREA CODE/PHONE COVER PAGE -PART 2 6. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE BALLOT NO . OR LETTER JURISDICTION o SUPPORT o OPPOSE Identify the controlling officeholder, candidate, or state measure proponent, If any. NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT OFFICE SOUGHT OR HELD I DIST~CT NO "ANV 7. Primarily Formed Candidate/Officeholder Committee List names of offlceholder(s) or candldate(s) for which this committee Is primarily formed. NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD o SUPPORT o OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD o SUPPORT o OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD o SUPPORT o OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD o SUPPORT o OPPOSE Attach continuation sheets If necessary FPPC Form 460 (Jan/2016) FPPC Advice: advlce@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Campaign Disclosure Statement Summary Page SEE INSTRUCTIONS ON REVERSE NAME OF FILER Maribeth Bushey for San Rafael City Council 2017 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 ....................................................................... Schedule H, 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 ................................ ScheduleB, Part 2 $ Cash Equivalents and Outstanding Debts 18. Cash Equivalents ................................................ See instructions on reverse $ 19. Outstanding Debts .............................. Add Line 2 + Line g in Column B abova $ Amounts may be rounded to whole dollars. ColumnA TOTAL THIS PERIOD (FROM ATIACHED SCHEDULES) o 350 350 7.36 7.36 350 SUMMARY PAGE Statement covers period January 1, 2017 from _________ _ CALIFORNIA 460 FORM through __ J_u_n_e_3_0_,_2_0_1_7_ 3 5 Page ___ of __ _ $ $ $ $ $ $ Column B CALENOAR YEAR TOTAL TO OATE o 350 350 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 fiied for this calendar year, only carry over the amounts from Lines 2, 7, and 9 (if any). 1.0. NUMBER 1358370 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 Volunlary ExpendIture Umlt) Date of Election (mm/dd/yy) Total to Date $----- $----- "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 Schedule B -Part 1 Loans Received SEE INSTRUCTIONS ON REVERSE NAME OF FILER Maribeth Bushey for San Rafael City Council 2017 FULL NAME, STREET ADDRESS AND ZIP CODE OF LENDER Amounts may be rounded to whole dollars. a OUTSTANDING AMOUNT BALANCE RECEIVED THIS (c) AMOUNT PAID OR FORGIVEN Statement covers period from __ J_a_nu_a_ry",--1..:.., _2_0_17 __ through June 30, 2017 e OUTSTANDING INTEREST BALANCE AT PAID THIS SCHEDULE B -PART 1 CALIFORNIA 460 FORM Page 4 of 5 1.0. NUMBER 1358370 II ORIGINAL CUMULATIVE AMOUNT OF CONTRIBUTIONS (IF COMMmEE. ALSO ENTER 1.0. NUMBER) IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (IF SELF·EMPLOYEO, ENTER NAME OF BUSINESS) BEGINNING THIS PERIOD PERIOD THIS PERIOD • CLOSE OF THIS PERIOD PERIOD LOAN TO DATE Maribeth Bushey 396 Riviera Dr San Rafael, CA 94901 t~ IND 0 COM OOTH 0 PTY 0 SCC to IND 0 COM OOTH 0 PTY 0 SCC to IND 0 COM OOTH 0 PTY 0 SCC Schedule B Summary Attorney AMS 25 Stillman San Francisco CA o PAID o FORGIVEN 350 o PAID o FORGIVEN o PAID o FORGIVEN SUBTOTALS $ $ 1. Loans received this period .................................................................................................................... $ (Total Column (b) plus unitemized loans of less than $100.) 2. Loans paid or forgiven this period ......................................................................................................... $ (Total Column (c) plus loans under $100 paid or forgiven.) (Include loans paid by a third party that are also itemized on Schedule A.) 3. Net change this period. (Subtract Line 2 from Line 1.) .............................................................. NET $ Enter the net here and on the Summary Page, Column A, Line 2. "Amounts forgiven or paid by another party also must be reported on Schedule A. •• If required. 350 ASAP DATE DUE DATE DUE DATE DUE $ 350 o 350 (May be a negative number) CALENDAR YEAR _0_% 3120 RATE PER ELECTION" 6l1BllZ DATE INCURRED CALENDAR YEAR -_% RATE PER ELECTION·· DATE INCURRED CALENDAR YEAR -_% RATE PER ELECTION" DATE INCURRED $ (Enle, (e) on Schedule E, Line 3) tContributor 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 (Jan/20i6) FPPC Advice: advice@fppc.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 _J_a_n_u_a-,ryc-1....:,_2_0_1_7_ CALIFORNIA 460 FORM SEE INSTRUCTIONS ON REVERSE through _J_u_n_e_3_0...:,_2_0_1_7_ Page _5 __ of_5 __ NAME OF FILER I.D.NUMBER Maribeth Bushey for San Rafael City Council 2017 1358370 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CMP campaign paraphemalia/misc . 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 fundraising 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 COMMITTEE, ALSO ENTER 1.0. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID California Secretary of State office semi annual payment to SOS Sacramento, CA FIL 50 Robin Frydday campaign photography Novato, CA PRO 300 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $ 350 Schedule E Summary 350 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 B, Part 1, Column (e).) ............................................................................. $ _____ _ 350 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/20I6) FPPC Advice: advlce@fppc.ca.gov (866/275-3772) www.fppc.ca.gov