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Home My WebLink AboutForm 460 - Samantha Sargent for City Council 2011 (2013-12-31) TerminationRecipient Committee Campaign Statement CoveriPage tGovernment Code Sections 84200-84216.5) SEE INSTRUCTIONS ON REVERSE Type or print In Ink. Stamp Statement covers period il Date of election If applicable: 07/01/2013 (Month, Day, Year) from YJ 12/31/2013 OAT#1 J' through 1. Type of Recipient Committee. All Committees — Complete Parts 1, 2, 3, and 4. Officeholder, Candidate Controlled Committee Primarily Formed Ballot Measure 0 State Candidate Election Committee Committee 0 Recall 0 Controlled (Also Complete Part 5) 0 Sponsored (Also Complete Part 6) General Purpose Committee 0 Sponsored 0 Small Contributor Committee 0 Political Party/Central Committee Primarily Formed Candidate/ Officeholder Committee (Also Ccm&te Part 7) 'J"I.D.NUNISER 3. CommIttee Information j �111' 1341306 COMMITTEE NAME (OR CANDIDATE'S NAME IF NO 60--m-ViTTEE) Samantha Sargent for San Rafael City Council 2011 STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODEIPHONE San Rafael Ca 94901 415-300-7898 MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL- FAX / E-MAIL ADDRESS i 11111 lip Page f o For Official Use Only [:] Preelection Statement Quarterly Statement JZ Semi-annual Statement Special Odd -Year Report EZ Termination Statement Supplemental Preelection (Also file a Form 410 Termination) Statement - Attach Form 495 Ej Amendment (Explain below) MAILING ADDRESS CITY STATE ZIP CODE AREA COD /PHONE OPTIONAL: FAX / E-MAIL ADDRESS Executed on Date By Sgwture of Contro&V Officox)lder, Cariddate, State Memure Proponent Executed on Dale By Sgnature of ControWng OfficOidder, Carvidate, State Measure Pmponent FPPC Form 460 (January/05) FPPC Toll -Free Helpfine: 866/ASK-FPPC (8661275-3772) State of Califomia T. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE ALLOT NO. OR LETTER FN 4^00' FORM Page 2 of SUPPORT OPPOSE Identify the controlling officeholder, candidate, or state measure proponent,, if any. OFFICE SOUGHT OR HELD HITT NO. IF ANY 7. Primarily.. Vii; e officeholder(s) or candidate(s) for which this committee is primarily formed. NAME OF OFFICEHOLDER OR CANDIDTT7�0�FFICFESOUGHT OR HELD 0 SUPPORT Attach continuation sheets if necessary FPPC Forfn 460 (January/05) FPPC THelpline: 866[ASK-FPPC (8661275-3772) Type print in Ink. %,ampaign Disclosure may . rounded Summary Page to whole s • NAME OF FILER Samantha Sargent for San Rafael City Council Statement covers period from 07/01/2013 M=# Contributions v ColumnA Column TOTALTHISPERICO ATTACHEDLES) CALENDAR TOTALTODATE ma.sm.. am aamas..saamaamasa.a a..a a.e •ma..m.am 1.onet Contributions,Schedule A, Line 22.50 22.50 2. Loans Received.............m...a....m.............................m. Schedule B, Lids . SUBTOTAL CASH CONTRIBUTIONS ....... ,add Lines I + 22.5 22.50 4. Nonmonetary Contributions .................................... Schedule C, Line 5. Tt TALO T I B TIO RECEIVED ama aaeam cmaasaam.eaeasm aaaa Add Lines 3 + 4 22.50 22.50 mw r Wo s Made 75 . Payments Made ............................a.......................... Schedule E, Lias 420. 7. Loans ade ............................................................. Schedule H, Line 8. SUBTOTAL CASH PAYMENTS Add Lines 6 + 3345 $ 4420.75 9. Accrued Expenses (Unpaid ills) ................a............. Schedule F Line 3 . Nonmonetary Adjustment .......................................... Schedule C, Line 3 11. TOTAL EXPENDITURES .......... Acid Lines 3 + 9 + 10 334 4420.75 12. Beginning Cash Balance ....................... Previous Summary Page, Line 2< 50 1 .as ReceiptsColumn A, Line 3 above 22-50 ,sena.mm.aaaaaammaa„,aamaaa.m...a.aa,aaa.ama,a.amm m Miscellaneous Increases to Cash........................... Schedule 1, Line 15. Cash Paymentsa...........aa..................................... Column A, Line b above 3345 16. ENDING CASH BALANCE .......... Add Lines 12 + 13 + 14, then subtract Line ff this is e termination statement, Lire 16 must be zero. 17. LOAN GUARANTEES RECEIVED........................... Schedule 6, Patt i Cash Equivalents and Outstanding Debts 1. Cash Equivalents........................a..a............ See instructions reverse 19.Outstandingt ........................... Add Line 2 + Line 9 in Column B above 12131/2013 ** O I.D. NUMBER s. Calendar ,. . for d • R Running in Both the State Primary and General ns 1/1 gh 6/30 711 to Date ..: 24. Contribution Received 21. Expenditures Made Expenditure i a tate Candidates 22. Cumulative ExpendituresMade* (If Subject to Voluntary Upenditure Limit) Sate of rection Total to Date mli reportedI *Amounts in this section may be different from amounts , FPPC Form 460 (January/05) CALIFORNIAStatement covers period I 7fr om 07/01/2013 FORM 4 SamanthaSEE INSTRUCTIONS ON REVERSE • Rafael •nc DATE FULL NAME, STREET ADDRESS AND ZIP ' CONTRIBUTOR CONTRIBUTOR RECEIVED (IF COMMITTEE, ALSO ENTER I.D. NUMBER) CODE OCCUPATION AND EMPLOYER (IF SELF-EMPLOYED, ENTER NAME Schedule A Summary 1. Amount received this period — itemized monetary contributions. (Includet t . A....s............................................................................#.......$ ..........a... period2. Amount received this 3. Total monetary contributions received this period. (Add Lines I and 2. Enter here and on the Summary Page, Column A, Line 1.) ....................... TOTAL $ FPPC Form 460 (January/ft) 12/31/2013 through Fags of F . UMBER 1341306 AMOUNT CUMULATIVE TO DATE PER ELECTION RECEIVED THIS CALENDAR YEAR TO DATE PERIOD (JAN. I - DEC. 31) (IF REQUIRED) *Contributor Codes IND - Individual COM - Recipient Committee (other than PTY or SCC) PTY - Political Party SCC - Small Contributor Committee All, NAME OF FILER Samantha Sargent for San Rafael City Council Type or print in ink. Amounts may be roundel to whole dollars. i Statement covers period 07/01/2013 from through 12/31/2013 pip Illiq I pill I I I I I 1 111 11111111 1 1 Page _j- Of I.D. NUMBER 1341306 CNP campaign paraphernalialmisc. KABR member communications RAD radio airtime and production costs CNS campaign consultants NI meetings and appearances RFD returned contributions CTB contribution (explain nonmonetary)* 0FC 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 TRIC candidate travel, lodging, and meals FND fundraising events POL polling and survey research TRS staff/spouse travel, lodging, and meals INID 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 Dorothy Cichon, San Rafael CA 94901 payment for campaign and and ongoing office CNS administration 3000 San Rafael PD K9 Association, 1400 Fifth St. San Rafael CA Ongoing program support CVC 200 San Rafael Police Association ongoing support CVC 145 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 3345 Schedule E Summary 1. Itemized payments made this period. (include all Schedule E subtotals.) .............................................................................................................. $ 3345 2. Unitemized payments made this period of under $100 .......................................................................................................................................... $ 4. Total payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.) ............................. TOTAL $ 3345 FPPC Form 460 (January/05)