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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)