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)