HomeMy WebLinkAboutForm 460 - Samantha Sargent for City Council 2011 (2011-10-22)Recipient Committee
Campaign Statement
Cover Page
(Government Code Sections 84200-84216.5)
SEE INSTRUCTIONS ON REVERSE
Type or print in ink.
Date Stamp
Statement covers period Date of election if applicable:
(Month, Day, Year)
from
through 1 1b j 2_ 1 j 2W i i
1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4.
® Officeholder, Candidate Controlled Committee ❑ Primarily Formed Ballot Measure
Q State Candidate Election Committee Committee
Q Recall Q Controlled
(Also Complete Part 5) Q Sponsored
(Also Complete Part 6)
❑ General Purpose Committee
Q Sponsored ❑ Primarily Formed Candidate/
Q Small Contributor Committee Officeholder Committee
Q Political Party/Central Committee (Also Complete Part 7)
3. Committee Information I I.D. NUMBER
COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE)
Samantha Sargent for San Rafael City Council 2011
CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX
CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX / E-MAIL ADDRESS
4. Verification
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 —4— of��
For Official Use Only
❑ Quarterly Statement
❑ 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 / 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 correct.
Executed on 101 Z 4 20, k By
Date -- Signature of Treaswer or Asstste tt Treasurer
Executed on t )i
Date
Executed on
Date
By
By
SatureofG der.G Stats MeasLre Pr
Executed on Date By Sqiahre of ControgffV Offx der, Canddate, State Measure Propermnt
FPPC Form 460 (January/05)
FPPC Toll -Free Helpline: 8661AStt-FPPC (566/275-3772)
State of California
Recipient Committee Type or print in ink. COVER PAGE - PART 2
Campaign Statement CA
�'
Cover Page — Part 2 460
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 CODEIPHONE
s• �
IFIVIT M. W.
NAME OF TREASURERI CONTROLLED COMMITTEE?
❑ YES ❑ NO
COMMITTEE ADDRESS STREETADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
Page 2 of l
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/05)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/2754772)
State of California
Campaign Disclosure Statement
Type or print in ink.
SUMMARY PAGE
Summary Page
Amounts may be rounded
to whole dollars.
$
Statement covers period
Q .
7. Loans Made............................................................. Schedule H, Line 3
0
C�12-5-126,,61
from 1
s ad'Aivi 0
$
2827.84
$ 6107.57
J
% 2�
Page 3
SEE INSTRUCTIONS ON REVERSE
0
10. Nonmonetary Adjustment .......................................... Schedule C, Line 3
through
of
NAME OF FILER
11. TOTAL EXPENDITURES MADE ................................ Add Lines 6 + 9 + 10
$
I.D. NUMBER
m�
Current Cash Statement
306,
Contributions Received
ColumnA
Column B
Calendar Year Summary for Candidates
To calculate Column B, add
TOTALTHISPERIOD
(FROM ATTACHED SCHEDULES)
CALENDAR YEAR
TOTALTODATE
Running in Both the State Primary and
amounts in Column A to the
General Elections
1. Monetary Contributions ........................................... Schedule A, Line 3
00
$ 240. $
5656.20
2. Loans Received...................................................... Schedule B, Line 3
550.00
550.00
1/1 through 6130 7/1 to Date
3. SUBTOTALCASH CONTRIBUTIONS ......................... Add Lines 1 + 2
$ 790.00 $
6206.20
20. Contributions
Received $ $
Column A may be negative
4. Nonmonetary Contributions .................................... Schedule C, Line 3
1250.00
3430.00
21. Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED ........•......... ••••.•.• Add Lines 3+4
$ 2040.00 $
9636.20
Made $ $
Expenditures Made
6. Payments Made ....................................................... Schedule E, Line 4
$
2827.84
$ 6107.57
7. Loans Made............................................................. Schedule H, Line 3
0
0
8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6 + 7
$
2827.84
$ 6107.57
9. Accrued Expenses (Unpaid Bills Schedule F, Line 3
0
0
10. Nonmonetary Adjustment .......................................... Schedule C, Line 3
0
0
11. TOTAL EXPENDITURES MADE ................................ Add Lines 6 + 9 + 10
$
2827.84
$ 6107.57
Current Cash Statement
12. Beginning Cash Balance ....................... Previous Summary Page, Line i6
$
2136.47
To calculate Column B, add
13. Cash Receipts ................................................... Column A, Line 3 above
790.00
amounts in Column A to the
0
corresponding amounts
14. Miscellaneous Increases to Cash ........................... Schedule 1, Line 4
from Column B of your last
15. Cash Payments .................................................. Column A, Line 6 above
282784
report. Some amounts In
Column A may be negative
16. ENDING CASH BALANCE .......... Add tines 12 + 13 + 14, then subtract Line 15
$
98.63
figures that should be
subtracted from previous
If this is a termination statement, Line 16 must be zero.
period amounts. If this is
the first report being filed
17. LOAN GUARANTEES RECEIVED ................" Schedule S. Part 2
" ...
$
for this calendar year, only
carry over the amounts
from Lines 2, 7, and 9 (if
Cash Equivalents and Outstanding Debts
any).
18. Cash Equivalents ........................................ See instructions on reverse
$
19. Outstanding Debts... ..... ........ ... .... Add Line 2 + Line gin Column B above
$
550.00
IExpenditure Limit Summary for State
Candidates
22. Cumulative Expenditures Made*
(If Subject to Voluntary Expenditure Limit)
Date of Election Total to Date
(mm/dd/yy)
$
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 (866/275-3772)
Schedule A Type or print In Ink. SCHEDULE A
nnwm�w clay un rvufweeu
MonetaryContributions Received to whole dollars.
_.. _
Statement covers period
{ l
1 �f
CALIFORNIA � ,
FORM
from/
through 6 2- -2
Page a
SEE INSTRUCTIONS ON REVERSE
of
NAME OF FILER
I.D. NUMBER
DATE
FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR
CONTRIBUTOR
IF AN INDIVIDUAL, ENTER
AMOUNT
CUMULATIVE TO DATE
PER ELECTION
RECEIVED
(IF COMMITTEE, ALSO ENTER I.D. NUMBER)
CODE *
OCCUPATIONANDEMPLOYER
RECEIVED THIS
CALENDAR YEAR
TO DATE
(IF SELF-EMPLOYED, ENTER NAME
OFBUSINESS)
PERIOD
(JAN. 1 -DEC. 31)
(IF REQUIRED)
❑IND
❑ COM
❑0TH
❑ PTY
❑ SCC
RIND
❑ COM
❑0TH
❑ PTY
❑ SCC
❑IND
❑COM
❑OTH
PTY
❑ SCC
❑IND
❑COM
❑ OTH
❑ PTY
❑SCG
❑ IND
[:]COM
❑ OTH
❑ PTY
❑ SCC
SUBTOTAL $
Schedule A Summary
1. Amount received this period — itemized monetary contributions. 0
(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 $
240.00
*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 (January/06)
FPPC Toll -Free Helpline: 8661ASK-FPPC (8661275-3772)
6�A
SCHIEDLA F R - PART 1
Schedule B — Part I Amounts may be rounded
Statement covers period
Loans Received to whole dollars.
"/-- / 1 7- 5-111
from —
D / 2-
SEE INSTRUCTIONS ON REVERSE
through
Page of
NAME OF FILER
I.D. NUMBER
— CX440
,C P14
/3cY 306
j
11
FULL NAME, STREET ADDRESS AND ZIP CODE
IF AN INDIVIDUAL, ENTER
AND EMPLOYER
(a)
OUTSTANDING
BALANCE
(b)
AMOUNT
lei
W
(d)
OUTSTANDING
BALANCEAT
(e)
INTEREST
(f)
ORIGINAL
(9)
CUMULATIVEOCCUPATION
OF LENDER
(IFCOMMrrTEE, ALSO ENTER I.D. NUMBER)
(IF SELF-EMPLOYED, ENTER
BEGINNING THIS
RECEIVED THIS
PERIOD
OR FORGIVEN
*
CLOSE OF THIS
PAID THIS
AMOUNT OF
CONTRIBUTIONS
NAMEOFBUSINESSI
PERIOD
THIS PERIOD
PERIOD
PERIOD
LOAN
TO DATE
Darren Sargent, 601 B Street, San
Sr. Software
F] PAID
CALENDAR YEAR
Rafael, Ca 94901
Development manager,
$ 0
$ 550.00
0
550.00
$ 550.00
Comcast
%
$
[] FORGIVEN
PER ELECTION"'"
RATE
550.00
$
550.00
$
$ 0
02/15/12
$
10/11
$ 550.00
tjO IND El COM El OTH Ej PTY El SCC
DATE DUE
DATE INCURRED
❑ PAID
CALENDAR YEAR
❑ FORGIVEN
PER ELECTION
RATE
DATE DUE
DATE INCURRED
t[] IND 0 COM ❑ OTH [:1 PTY [:1 SCC
E] PAID
CALENDAR YEAR
❑ FORGIVEN
PER ELECTION""'
RATE
tC] IND El COM El OTH El PTY Ej SCC
I
I
DATE DUE
DATE INCURRED
SUBTOTALS $ 550.00$ 0 $ 550.00 $ 0
Schedule B Summary
1. Loans received this period ..................................................... ............ ...... $ 550.00
(Total Column (b) plus unitemized loans of less than $100.)
2. Loans paid or forgiven this period ... . .... _ ...... .......................... _ ............. .............................. _'_ ........ $ 0
(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.) ................... .......... ........ ........... NET $ 550.00
Enter the net here and on the Summary Page, Column A, Line 2. (May be a negative number)
.Amounts forgiven or paid by another party also must be reported on Schedule A.
— If required.
(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 (January/06)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)
Schedule C Type or print in ink.
A qrHr-ni ii F C.,
Nonmonetary Contributions Received ...y ... .
to whole dollars.
Statement covers period I
—_
from -1
CALIFORNIA 460
FORM
through 42 l 2 -2
Page
SEE INSTRUCTIONS ON REVERSE
I
of
NAME OF FILER
I.D. NUMBER
/3N7
DATE
FULL NAME, STREET ADDRESS AND
CONTRIBUTOR
IF AN INDIVIDUAL, ENTER
OCCUPATION AND EMPLOYER
DESCRIPTION OF
AMOUNT/
FAIR MARKET
CUMULATIVE TO
DATE
j
PER ELECTION
RECEIVED
ZIP CODE OF CONTRIBUTOR
(IF COMMITTEE, ALSO ENTER I.D. NUMBER)
CODE
(IF SELF-EMPLOYED, ENTER
NAME OF BUSINESS)
GOODS OR SERVICES
VALUE
CALENDAR YEAR
TO DATE
IF REQUIRED
()
(JAN I - DEC 31)
Erik Dillinger, San Rafael,
®IND
Graphic Producer,
Graphic Design
10/16/2011
Ca 94901
nCOM
Lucas Films
1000.00
2000.00
1710TH
nPTY
r-ISCC
Amy Likover, JEW, San
®INDRetired
Signs
10/22/2011
Rafael, Ca 949171-
RCOM
250.00
250.00
MOTH
M PTY
EISCC
E]IND
r--lCOM
MOTH
MPTY
f-jSCC
RIND
RCOM
MOTH
nPTY
[:]SCC
Attach additional information on appropriately labeled continuation sheets. SUBTOTAL $ 1250.00 F
Schedule C Summary
1. Amount received this period — itemized nonmonetary contributions.
(include all Schedule C subtotals.) ..... ....... ... __ ............... .......
2. Amount received this period — uniternized 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.) .
..... .... . $
�j
1250.00
0
1250.00
*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 (January/05)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)
Schedule E Type or print in ink.
Amounts may be rounded Statement covers period
Payments Made to whole dollars. from - 2 Al,'- / //
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
0
through 10! '2- -2- / //
CODES: If one of the following codes accbfately describes the payment, you may enter the code. Otherwise, describe the payment
Page -a— of
UMBER
/3a6,
CW
campaign paraphemalia/misc.
lVW
member communications
RAD
radio airtime and production costs
CNS
campaign consultants
UM
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
PFD
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
Marin Independant Journal, 4000 Civic Center Drive, San Rafael, ca 94903
Ad
1078.13
SpeedPro Imaging, 1495 E. Francisco, Blvd, San Rafael, Ca 94901
Signs
507.78
ScanArt, 1259 Park Ave, Emeryville, CA 94608
door hangers
1241.93
* Payments that are contributions or independent expenditures must also be summarized on Schedule D.
Schedule E Summary
1. Itemized payments made this period. (Include all Schedule E subtotals.).. . ................ ........... ....................
2. Uniternized payments made this period of under $100 .......... _ .......... ......... .............. ..... _ ... _._ ......
3. Total interest paid this period on loans. (Enter amount from Schedule B, Part 1, Column (e).) ......................................
4. Total payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.).
SUBTOTAL$
..........I .......... ......... .... $
...... 1.11- ... .... TOTAL $
2827.84
0
0
2827.84
FPPC Form 460 (January/05)
FPPC Toll -Free Helpline: 8661ASK-FPPC (866/276-3772)