HomeMy WebLinkAboutForm 460- Rachel Kertz for City Council 2020 (2023-06-30); terminationRecipient Committee
Campaign Statement
Cover Page
(Government Code Sections 84200-84216.5)
Statement covers period
from � 1 4_g�s
SEE INSTRUCTIONS ON REVERSE ( through
1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4.
0 Officeholder, Candidate Controlled Committee
0 State Candidate Election Committee
Q Recall
(Also Complete Part 5)
❑ General Purpose Committee
Q Sponsored
Q Small Contributor Committee
Q Political Party/Central Committee
3. Committee Information
❑ Primarily Formed Ballot Measure
Committee
Q Controlled
Q Sponsored
(Also Complete Part 6)
❑ Primarily Formed Candidate/
Officeholder Committee
(Also Complete Part 7)
I.D. NUMBER
1427074
COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE)
Rachel Kertz for City Council 2020
STREET ADDRESS (NO P.O. BOX)
CITY
Antelope
STATE ZIP CODE AREA CODE/PHONE
CA 95843 (
MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX
COVER PAGE
■
Date of election if app
(Month, Day, Year
i
[�)jage
1 Ci
of
For Official Use Only
11/03/2020
5 OFFICE
2. Type of Statement:
❑ Preelection Statement
❑
Quarterly Statement
[ Semi-annual Statement
❑
Special Odd -Year Report
D;P Termination Statement
❑
Supplemental Preelection
(Also file a Form 410 Termination)
Statement - Attach Form 495
❑ Amendment (Explain below)
Treasurer(s)
NAME OF TREASURER
Chelsea Johnson
MAILING ADDRESS
CITY
STATE
ZIP CODE AREA CODE/PHONE
Antelope
CA
95843 (
NAME OF ASSISTANT TREASURER, IF ANY
MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE C
STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX / E-MAIL ADDRESS OPTIONAL: FAX / E-MAIL ADDRESS
(
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. I certify
Measure Proponent or Responsible Officer of Sponsor
Executed on
Date
Executed on
Date
By
Signature of Controlling Officeholder, Candidate, State Measure Proponent
By
Signature of Controlling Officeholder, Candidate, State Measure Proponent
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (8661275-3772)
www.fppc.ca.gov
Recipient Committee
Campaign Statement
Cover Page — Part 2
COVER PAGE - PART 2
CALIFORNIA
FORM -r60
[Page 2 of 9
5. Officeholder or Candidate Controlled Committee
6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHOLDER OR CANDIDATE
NAME OF BALLOT MEASURE
Rachel Kertz
OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE)
BALLOT NO. OR LETTER JURISDICTION ❑ SUPPORT
City Council Member City of San Rafael District 4
❑ OPPOSE
RESIDENTIAL/BUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP
Identify the controlling officeholder, candidate, or state measure proponent, if any.
San Rafael CA 94903
NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT
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
OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
contributions or make expenditures on behalf of your candidacy.
COMMITTEE NAME I.D. NUMBER
7. Primarily Formed Candidate/Officeholder Committee List names of
NAME OF TREASURER CONTROLLED COMMITTEE?
officeholder(s) or candidate(s) for which this committee is primarily formed.
❑ YES ❑ NO
COMMITTEE ADDRESS STREETADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
COMMITTEE NAME I.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE?
❑ YES ❑ NO
COMMITTEE ADDRESS STREETADDRESS (NO P.O. BOX)
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
CITY STATE ZIP CODE AREA CODE/PHONE Attach continuation sheets if necessary
www.netfile.com
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppe.ca.gov
Campaign Disclosure Statement SUMMARYPAGE
Amounts may be rounded Statement covers period • -
Summary Page to Whole dollars. NIA '
from 01/01/2023 •_
through
06/30/2023
Page 3 of 9
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
I.D. NUMBER
Rachel Kertz for City Council 2020
1427074
AoD
Column B
Calendar Year Summary for Candidates
Contributions Received
ToColumn
Running in Both the State Prima and
(FROM ATTACHED SCHEDULES)
TOTALTO DATE
General Elections
1. Monetary Contributions
Schedule A, Line
$ 16,000.00 $
16,000.00
1/1 through 6/30 7/1 to Date
2. Loans Received......................................................
Schedule B, Line 3
-16,000.00
0.00
3. SUBTOTAL CASH CONTRIBUTIONS .........................
Add Lines 1 +2
$ 0.00 $
16, 000.00
20. Contributions
Received $ $
4. Nonmonetary Contributions ....................................
Schedule C, Line 3
186.75
186.75
21 Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED ...........................
Add Lines 3+4
$ 186.75 $
16,186.75
Made $ $
Expenditures Made
6. Payments Made .......................................................
Schedule E, Line 4 $
7. Loans Made.............................................................
Schedule H, Line 3
8. SUBTOTALCASH 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 1, 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 $
521.83 $
0.00
521.83 $
-221.75
186.75
486.83 $
521.83
0.00
521.83
0.00
186.75
708.58
521.83
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
0.00
0.00
521.83
0.00
0.001
Equivalents and Outstanding Debts from Lines 2, 7, and 9 (if
Cash E
�i 9 any).
18. Cash Equivalents ........................................ See instructions on reverse $ 0.00
19. Outstanding Debts ......................... Add Line 2 +Line 9 in Column B above $ 0.00
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:xpenditure Limit Summary for State
'andidates
22. Cumulative Expenditures Made*
(If Subject to Voluntary Expenditure Limit)
Date of Election Total to Date
(mm/dd/yy)
f
Amounts in this section may be different from amounts
eported in Column B.
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Cr-horli do A
SCHEDULE A
— - - - Amounts may be rounded
Monetary Contributions Received to whole dollars.
Statement covers period
CALIFORNIA '
from 01/01/2023
FORM
through 06/30/2023
Page 4 of 9
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
I.D. NUMBER
Rachel Kertz for City Council 2020
1427074
DATE
DE O
FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR
ZIP
E(IF
CONTRIBUTOR
IF AN INDIVIDUAL, ENTER
OCCUPATION AND EMPLOYER
AMOUNT
RECEIVED THIS
CUMULATIVETO DATE
CALENDAR YEAR
PER ELECTION
TO DATE
RECEIVED
COADDRE,ALSAND
I.D.N
CODE *
(IF SELF-EMPLOYED, ENTER NAME
PERIOD
(JAN. 1 - DEC. 31)
(IF REQUIRED)
OFBUSINESS)
06/30/2023
Rachel Kertz
®IND
Candidate
6,000.00
16,000.00
❑ COM
Candidate
San Rafael, CA 94903
❑ OTH
Loan Forgiven
❑ PTY
❑ SCC
06/30/2023
Rachel Kertz
®IND
Candidate
10,000.00
16,000.00
❑ COM
Candidate
San Rafael, CA 94903
❑ OTH
Loan Forgiven
❑ PTY
❑ SCC
❑IND
❑ COM
❑ OTH
❑ PTY
❑ SCC
❑IND
❑ COM
❑ OTH
❑ PTY
❑ SCC
❑IND
❑COM
❑ OTH
❑ PTY
❑ SCC
SUBTOTAL$ 16, 000.00
Schedule A Summary
1. 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 $
16,000.00
0.00
16,000.00
"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 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (8661275-3772)
www.fppc.ca.gov
www.netfile.com
Schedule B — Part 1 Amounts may be rounded
Statement covers period
0.
, • '
Loans Received to whole dollars.
01/01/2023
• .
from
SEE INSTRUCTIONS ON REVERSE
through 06/30/2023
Page 5 of 9
NAME OF FILER
I.D. NUMBER
Rachel Kertz for City Council 2020
1427074
FULL NAME, STREET ADDRESS AND ZIP CODE
IF AN INDIVIDUALENTER
,
a
OUTSTANDING
(b)
AMOUNT
(c)
AMOUNT PAID
(d)
OUTSTANDING
(e)
INTEREST
M
ORIGINAL
W
CUMULATIVE
OF LENDER
OCCUPATION AND EMPLOYER
(IF SELF-EMPLOYED, ENTER
BALANCE
BEGINNING THIS
RECEIVED THIS
OR FORGIVEN
BALANCEAT
CLOSE OF THIS
PAID THIS
AMOUNT OF
CONTRIBUTIONS
(IF COMMITTEE, ALSO ENTERI.D.NUMBER)
NAME OF BUSINESS)
PERIOD
PERIOD
THIS PERIOD*
PERIOD
PERIOD
LOAN
TO DATE
Rachel Kertz
Candidate
❑ PAID
CALENDARYEAR
11
San Rafael, CA 94903
$ n no
$ n on
n nn/
$ e.000.00
$ 16.000.00
[Z FORGIVEN
PERELECTION-
RATE
$ 6, 000.00
$ 0.00
$ r 000.00
06/18/2021
$ n nn
12/18/2020
$
DATE DUE
DATE INCURRED
tZ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC
Rachel Kertz
Candidate
❑ PAID
CALENDAR YEAR
11
San Rafael, CA 94903
$ n- nn
$ n nn
n_nn/
$ 10,000.00
$ 16.000_nn
FORGIVEN
PER ELECTION**
RATE
$ 10,000.00
$ 0.00
$ in, 00o no
07/22/2021
$ n nn
01/22/2021
$
DATE DUE
DATE INCURRED
tFC1 IND ❑ COM ❑ OTH ❑ PTY ❑ SCC
❑ PAID
CALENDARYEAR
❑ FORGIVEN
PERELECTION—
RATE
DATE DUE
DATE INCURRED
t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC
SUBTOTALS $ 0.00$ 16,000.00$ 0.00$ 0.00
Schedule B Summary
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.) ................
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.
iM L ' R M 1L
0.00
16,000.00
NET $ -16, 000.00
(May be a negative number)
(Enter (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/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Sr_har•li lip C
WT110.1057111110701
Amounts may oe rounaea
Nonmonetary Contributions Received to whole dollars.
Statement covers period
• ' '
,
from 01/01/2023
• -
through 06/30/2023
Page 6 of 9
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
I.D. NUMBER
Rachel Kertz for City Council 2020
1427074
FULL NAME, STREET ADDRESS AND
CONTRIBUTOR
IF AN INDIVIDUAL, ENTER
DESCRIPTION OF
AMOUNT/
CUMULATIVE TO
DATE
PER ELECTION
DATE
RECEIVED
ZIP CODE OF CONTRIBUTOR
CODE r
OCCUPATION AND EMPLOYER
(IF SELF-EMPLOYED, ENTER
GOODS OR SERVICES
FAIR MARKET
VALUE
CALENDAR YEAR
TO DATE
IF REQUIRED
( )
(IF COMMITTEE, ALSO ENTER I.D. NUMBER)
NAME OF BUSINESS)
(JAN 1 - DEC 31)
6/30/2023
Loren Kertz
]IND
Bill Forgiven
43.00
186.75
❑COM
San Rafael, CA 94903
❑ OTH
❑ PTY
❑SCC
6/30/2023
Loren Kertz
]IND
Bill Forgiven
143.75
186.75
❑COM
San Rafael, CA 94903
❑ OTH
❑ PTY
❑ SCC
RIND
❑COM
❑ OTH
❑ PTY
❑ SCC
❑IND
❑COM
❑ OTH
❑ PTY
❑ SCC
Attach additional information on appropriately labeled continuation sheets. SUBTOTAL $ 186.75
Schedule C Summary
1. Amount received this period — itemized nonmonetary contributions.
(Include all Schedule C subtotals.)..................................................................
2. Amount received this period — unitemized nonmonetary contributions of less than $100
3. Total nonmonetary contributions received this period.
(Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Lines 4 and 10.)
$ 186.75
....... $
..... TOTAL $
0.00
186.75
`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 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
www.netfile.com
6Yi7:1��1�1!�
Schedule E
Payments Made
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
Rachel Kertz for City Council 2020
Amounts may be rounded
to whole dollars.
Statement covers period
from 01/01/2023
through 06/30/2023
CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment.
Page 7 of 9
I.D. NUMBER
1427074
CMP
campaign paraphernalia/misc.
MBR
member communications
RAD
radio airtime and production costs
CNS
campaign consultants
MTG
meetings and appearances
RFD
returned contributions
CTB
contribution (explain nonmonetary)'
OFC
office expenses
SAL
campaign workers' salaries
CVC
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
FIND
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 (internet, e-mail)
NAME AND ADDRESS OF PAYEE
(IF COMMITTEE, ALSO ENTER I.D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNTPAID
CJ & Associates, Inc. PRO 35.00
Antelope, CA 95843
CJ & Associates, Inc. PRO 142.71
Antelope, CA 95843
CJ & Associates, Inc. I PRO I 1 105.18
Antelope, CA 95843
* Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 282.89
Schedule E Summary
1. Itemized payments made this period. Include all Schedule E subtotals. 471.83
2. Unitemized payments made this period of under $100.......................................................................................................................................... $ 50.00
3. Total interest paid this period on loans. (Enter amount from Schedule B, Part 1, Column (e).)............................................................................... $ 0.00
4. Total payments made this period. Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6. TOTAL $ 521.83
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FPPC Form 460 (Jan/2016)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)
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Schedule E
SCHEDULE E (CONT.)
(Continuation Sheet) Amounts may be rounded Statement covers period • _ ,
to whole dollars. • '
Payments Made from 01/01/2023
SEE INSTRUCTIONS ON REVERSE through 06/30/2023 page 8 of 9
NAME OF FILER I.D. NUMBER
Rachel Kertz for City Council 2020 1427074
CODES: If one of the following codes accurately describes the payment, you may enter the code.
Otherwise, describe the payment.
CMP
campaign paraphernalia/misc.
MBR
member communications
RAID
radio airtime and production costs
CNS
campaign consultants
MTG
meetings and appearances
RFD
returned contributions
CTB
contribution (explain nonmonetary)"
OFC
office expenses
SAL
campaign workers' salaries
CVC
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 (internet, e-mail)
NAME AND ADDRESS OF PAYEE
(IF COMMITTEE, ALSO ENTER I.D. NUMBER)
CODE OR DESCRIPTION OF PAYMENT
AMOUNT PAID
CJ & Associates, Inc.
Antelope, CA 95843
PRO
188.94
* Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $ 188. 94
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FPPC Form 460 (Jan/2016)
FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772)
www.fppe.ca.gov
SCHEDULEF
Schedule F Statement covers period • -
Amounts may be rounded / � '
Accrued Expenses (Unpaid Bills) to whole dollars. from 01/01/2023 •
through 06/30/2023 Page 9 of 9
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER I.D. NUMBER
Rachel Kertz for City Council 2020 1427074
CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment.
CMP
campaign paraphernalia/misc.
MBR
member communications
RAID
radio airtime and production costs
CNS
campaign consultants
MTG
meetings and appearances
RFD
returned contributions
CTB
contribution (explain nonmonetary)*
OFC
office expenses
SAL
campaign workers' salaries
CVC
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
FIND
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 (internet, e-mail)
(a)
(
(c)
(
NAME AND ADDRESS OF CREDITOR
CODE OR
OUTSTANDING
AMOUNTIN INCURRED
AMOUNT PAID
OUTSTANDING
(IF COMMITTEE, ALSO ENTER I.D. NUMBER)
DESCRIPTION OF PAYMENT
BALANCE BEGINNING
THIS PERIOD
THIS PERIOD
BALANCE AT CLOSE
OF THIS PERIOD
(ALSO REPORT ON E)
OF THIS PERIOD
CJ & Associates, Inc.
PRO
35.00
0.00
35.00
0.00
Antelope, CA 95843
Loren Kertz
OFC
43.00
-43.00
0.00
0.00
San Rafael, CA 94903
Loren Kertz
WEB
143.75
-143.75
0.00
0.00
San Rafael, CA 94903
* Payments that are contributions or independent expenditures must also be SUBTOTALS $ 221.75$-186.75$ 35. 00$ 0.00
summarized on Schedule D.
Schedule F Summary
1. Total accrued expenses incurred this period. (Include all Schedule F, Column (b) subtotals for
accrued expenses of $100 or more, plus total unitemized accrued expenses under$100.).......................................
2. Total accrued expenses paid this period. (Include all Schedule F, Column (c) subtotals for payments on
accrued expenses of $100 or more, plus total unitemized payments on accrued expenses under $100.) .................
3. Net change this period. (Subtract Line 2 from Line 1. Enter the difference here and
on the Summary Page, Column A, Line 9.)................................................................................................................
INCURRED TOTALS $
PAID TOTALS $
-186.75
35.00
..................... NET $ -221.75
May be a negative number
FPPC Form 460 (Jan/2016)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)
www.netfile.com www.fppc.ca.gov