HomeMy WebLinkAboutForm 460 - Paramedic Services PAC (2017-06-30)Recipient Committee
Campaign Statement
Cover Page
Statement covers period
from ____ 1_1_1/_2_0_17 __ _
SEE INSTRUCTIONS ON REVERSE 6/30/2017 through ________ _
1. Type of Recipient Committee: All Committees -Complete 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 Complele Part 5)
~ General Purpose Committee o Sponsored
® Small Contributor Committee o Political Party!Central Committee
® Controlled o Sponsored
(Also Complele Part 6)
o Primarily Formed Candidate!
Officeholder Committee
(Aiso Complele Pert 7)
I.D.NUMBER
1075199
Committee for San Rafael Paramedic Services
STREET ADDRESS (NO P.O. BOX)
CITY
San Rafael
STATE ZIP CODE
CA 94903
MAILING ADDRESS (IF DIFFERENT) ND. AND STREET OR P.O. BOX
CITY STATE ZIP CODE
OPTIONAL: FAX / E-MAIL ADDRESS
AREA CODEIPHONE
AREA CODEIPHONE
4. Verification
I have used all reasonable di 'gence 'n preparing and reviewing this statement and to the best of my
certify under penalty of pe' ry und r the laws of the State of California that the foregoing is true (j
Executed on -+-/-:".&.~-I:::,.:::;::;'-';:..L...,f----
Executed on _-'-___ ....,.,=-_____ _
Date of election If app
(Month, Day, Year)
CITY CLERK'S 0
2. Type of Statement:
o Preelection Statement
1121 Semi-annual Statement o Termination Statement
(Also file a Form 410 Termination)
o Amendment (Explain below)
Treasurer(s)
NAME OF TREASURER
Greg Knell
MAILING ADDRESS
same
CITY
NAME OF ASSISTANT TREASURER, IF ANY
MAILING ADDRESS
CITY
OPTIONAL: FAX / E-MAIL ADDRESS
o Quarterly Statement o Special Odd-Year Report
STATE ZIP CODE AREA CODE/PHONE
STATE ZIP CODE AREA CODE/PHONE
Executed on -----....,.,Da~te~------BY-----~S~lg=ne~tu=re70of~c=on~tro~lIln=gnO~ffic~eh=ol~de~~~Ca=nd~ld~at~e,~S~~te~M~e=as~um~P~ro=po=n=en7t-----
Executed on -----'D:..a:::te:--------By _________ ~~~~~~~~~~~~~~~~~~~---------Signature of Controlling Officeholder, Candidate, State Measure Proponent
FPPC Form 460 (Jan/2016)
FPPC Advice: adv(ce@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Campaign Disclosure Statement
Summary Page
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
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 c, Line 4 $
7. Loans Made....................................................................... Schedule H, Line 3
8. SUBTOTAL CASH PAyMENTS .......................................... AddLines6+7 $
9. Accrued Expenses (Unpaid Bills) .......................................... Schedule F, Line 3
10. Nonmonetary Adjustment.. ....................................................... Schedule C, Line 3
11. TOTAL EXPENDITURES MADE ........................................ Add Lines B + 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 B 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 91n Column B above $
Amounts may be rounded
to whole dollars.
ColumnA
TOTAL THIS PERIOD
(FRO M ATTACHED SCHEDULES)
5,202.58
o
5,202.58
o
o
o
SUMMARY PAGE
Statement covers period CALIFORNIA 460
FORM 1/1/2017 from _________ _
4 6/30/2017 through _______ _ Page ___ of __ _
$
$
$
$
$
$
Column B
CALENDAR YEAR
TOTAL TO DATE
To calculate Column B,
add amounts in Column
A to the corresponding
amounts from Column B
o
o
o
o
o
o
o
o
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).
I.D. NUMBER
1075199
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 Voluntary Expondlture Limit)
Date of Election
(mm/dd/yy)
----1----1 __
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 A
Monetary Contributions Received
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
Amounts may be rounded
to whole dollars.
DATE
RECEIVED
FULL NAME. STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR
(IF COMMITTEE. ALSO ENTER 1.0. NUMBER) CODE *
IF AN INDIVIDUAL. ENTER
OCCUPATION AND EMPLOYER
(IF SELF·EMPLOYED. ENTER NAME
OF BUSINESS)
Schedule A Summary
DINO
DeOM
DOTH
DpTY
Dsee
DIND
DeoM
DOTH
DpTY
Osee
DINO
DeOM
DOTH
DpTY
Dscc
DINO
DCOM
DOTH
DpTY
Dscc
DINO
DeOM
DOTH
DpTY
Osee
SUBTOTAL $
SCHEDULE A
Statement covers period CALIFORNIA 460
FORM from ___ 1_'1_'2_0_1_7 __ _
through __ 6_'_30_'_2_0_17 __ Page _3 __ of __ 4_
AMOUNT
RECEIVED THIS
PERIOD
I.D. NUMBER
1075199
CUMULATIVE TO DATE
CALENDAR YEAR
(JAN. 1 -DEC. 31)
PER ELECTION
TO DATE
(IF REQUIRED)
'Contributor Codes
INO -Individual 1. Amount received this period -itemized monetary contributions.
(Include all Schedule A subtotals.) ......................................................................................................... $ ______ 0 COM -Recipient Committee
(other than PTY or SCC)
OTH -Other (e.g .• business entity)
PTY -Political Party 2. Amount received this period -unitemized monetary contributions of less than $100 ........................... $ ______ 0
3. Total monetary contributions received this period.
(Add Lines 1 and 2. Enter here and on the Summary Page. Column A. Line 1.) ...................... TOTAL $ ______ 0
SCC -Small Contributor Committee
FPPC Form 460 (Jan/2016)
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 ___ 1/_1_/2_0_1_7 __
CALIFORNIA 460
FORM
SEE INSTRUCTIONS ON REVERSE
through __ 61_3_0_/2_0_1_7 __ Page _4 __ of_4 __
NAME OF FILER I.D . NUMBER
1075199
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 RAO 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 fundraislng 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 1.0 . NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID
* Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $
Schedule E Summary
o 1. Itemized payments made this period. (Include all Schedule E subtotals.) ............................................................................................................. $ _____ _
o 2. Unitemized payments made this period of under $100 .......................................................................................................................................... $ _____ _
o 3. Total interest paid this period on loans . (Enter amount from Schedule B, Part 1, Column (e).) ............................................................................. $ _____ _
o 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 Forrn 460 (Jan/2016)
FPPC Advice: advice@fppc,ca.gov (866/275-3772)
www.fppc.ca.gov