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HomeMy WebLinkAboutForm 460 - Samantha Sargent for City Council 2011 (2011-12-31)Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200-84216.5) SEE INSTRUCTIONS ON REVERSE Type or print in ink. Statement covers period from - 110 Z-2- C i i through 1. Type of Recipient Committee: All Committees – Complete Parts 1, 2, 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 ❑ General Purpose Committee (At- Complete Part 6) 0 Sponsored F-1 Primarily Formed Candidate/ 0 Small Contributor Committee Officeholder Committee 0 Political Party/Central Committee (Also Complete Part 7) . 3. Committee Information 1 I.DNUMBER NU4 "% '• � COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) Samantha Sargent for San Rafael City Council 2011 STREET ADDRESS (NO P.O. BOX) 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 I E-MAIL ADDRESS 4. Verification Date Stamp Date of election if applicable: (Month, Day, Year) 11/8/2011 2. Type of Statement: Preelection Statement ❑ Semi-annual Statement ❑ Termination Statement (Also file a Form 410 Termination) ❑ Amendment (Explain below) Treasurer(s) COVER PAGE Page of For Official use Only ❑ Quarterly Statement F-1 Special Odd -Year Report ❑ Supplemental Preelection Statement - Attach Form 495 NAME OF TREASURER Darren Sargent MAILING ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE San Rafael Ca 94901 NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL: FAX I E-MAIL ADDRESS 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 under penalty of perjury under the laws of the State of California that the foregoing is true and corr, Executed on t3o' ,t— By Date V re of Treasurer or A Executed on t IX, Byc Date Executed on Date Executed on Date Clear Cov r Pg! By Sig -lure of Controilkler, Carididate, State Measure Propmem By SKineft" Of Cer. Cand1date State Measure PrODonent Print Form FPPC Form 460 (January/06) FPPC Toll -Free Helpline: 8661ASK-FPPC (8661276-3772) State of Callfomla Recipient Committee Type or print in ink. COVER PAGE - PART 2 Campaign Statement F'. A 460 Cover Page — Part 2 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Samantha Sargent OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) San Rafael City Council RESIDENTIAUBUSINESS 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? ❑ 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 STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE Clear Cover Pg2 Page 2 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 DISTRICT NO. IF ANY 7. Primarily Formed Candidate/Officeholder Committee List names of officeholder(s) or candidates) 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 ❑ SUPPORT ❑ OPPOSE 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 Form 460 (January/06) FPPC Toll -Free Helpline: 8661ASK-FPPC (8661275-3772) State of California Campaign Disclosure Statement Type or print in ink. Amounts may be rounded Summary Page to whole dollars. SEE INSTRUCTIONS ON REVERSE NAME OF FILER PAGE Statement covers period CALIFORNIA from b FORM 46'- through &�- ZA 2-C! 3 Page - of I.D. NUMBER 1-1/ Contributions Received Column A Column B Calendar Year Summary for Candidates TOTALTHIS PERIOD (FROM ATTACHED SCHEDULES) CALENDAR YEAR TOTALTO DATE Running in Both the State Primary and General Elections 1. Monetary Contributions ..................... ............. Schedule A, Line 3 $ 225 $ 5656.20 2. Loans Received ...................................................... Schedule B, Line 3 0 550 1/1 through 6/30 7/1 to Date 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines I + 2 $ 225 $ 6431.20 20. Contributions Received $ $ 4. Nonmonetary Contributions .... ............................... schedule C, Line 3 0 3530 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED ........... ............... Add Lines 3 + 4 $ 225 $ 9861.20 Made $ $ Expenditures Made 6. Payments Made ............... ............ .................. Schedule E, Line 4 $ 85.39 $ 7. Loans Made ..... ................. ............ .......... ............. Schedule H, Line 3 0 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6 + 7 $ 85.39 $ 9. Accrued Expenses (Unpaid Bills) ............................... Schedule F, Line 3 0 10. Nonmonetary Adjustment .......................................... schedule C, Line 3 0 11. TOTAL EXPENDITURES MADE. ..... -- ........... ....... - Add Lines 8 + 9 + 10 $ 85.39 $ 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 /, 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. I 85.39 238.24 17. LOAN GUARANTEES RECEIVED., ......... ......... Schedule 8, Part 2 $ 0 Cash Equivalents and Outstanding Debts 18. Cash Equivalents.. ..... ......... - ....... ..... See instructions on reverse $ 0 19. Outstanding Debts .. ...... ......... ... Add Line 2 + Line 9 in Column B above $ 550 MRAK-1 0 6192.96 Expenditure Limit Summary for State Candidates 22. Cumulative Expenditures Made* (if Subject to Voluntary Expenditure Un'dt) Date of Election Total to Date (mm/dd/yy) 6192.96 1 $ 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). *Amounts in this section may be different from amounts reported in Column B. FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) ScheduleA Type or print in ink. SCHEDULE A Monetary Contributions Received Amounts may be rounded Statement covers period to whole dollars./ CALIFORNIA 460 from FORM through Page SEE INSTRUCTIONS ON REVERSE Of - NAME OF FILER I.D. NUMBER DATE FULL NAME, STREET ET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION RECEIVED COMMITTEE (IF , ENTER I.D. NUMBER) ALSO CODE OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. 1 -DEC. 31) (IF REQUIRED) OF BUSINESS) Jonathan Frieman, ®IND r-1 COM Self employed 12/08/11 San Rafael, CA 94901 $100 $100 F-1 OTH F-1 PTY MSCC F-1 IND F-1COM [-] OTH El PTY ❑ SCC ❑ IND 000M f -I OTH [:] PTY EISCG ❑ IND ❑ com M OTH ❑ PTY F-1SCC F-JIND r-iCOM E] OTH ❑ PTY ❑ SCC SUBTOTAL$ 100 Schedule A Summary 1. Amount received this period — itemized monetary contributions. 100 (Include all Schedule A subtotals.) ....... ............ ......... ................... .......... $ 2. Amount received this period — uniternized monetary contributions of less than $100 ..................... $ 125 3. Total monetary contributions received this period. 225 (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1 ....................... TOTAL $ *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 E Type or print in ink. Statement covers period Payments Made Amounts may be rounded _ y to whole dollars. from SEE INSTRUCTIONS ON REVERSE through f Page 5 of NAME OF FILER I.D. NUMBER z CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CNP campaign paraphemalia/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 FND fundraising events POL polling and survey research TRS staff/spouse travel, lodging, and meals M independent expenditure supporting/opposing others (explain)* PUS 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 IIF COMMITTEE, ALSO ENTER I D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNTPAID * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $ Schedule E Summary 1. Itemized payments made this period. include all Schedule E subtotals. 0 2. Unitemized payments made this period of under $100 ......................................... 85.39 3. Total interest paid this period on loans. Enter amount from Schedule B, Part 1, Column (e). 0 4. Total payments made this eriod. {Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.} ........ TOTAL $ 85.30 FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)