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Home My WebLink AboutForm 460 - Samantha Sargent for City Council 2011 (2011-09-24)Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200-84216.5) SEE INSTRUCTIONS ON REVERSE Type or print in ink. Statement; doyerg period 1 - from— I /# t�-Icll through �1-21'2z, I i 1. Type of Recipient Committee: All Committees – Complete Parts 11, 2, 3, and 4. officeholder, Candidate Controlled Committee F-1 Primarily Formed Ballot Measure 0 State Candidate Election Committee Committee 0 Recall 0 Controlled (Also Complete Part 5) 0 Sponsored (Also Complete Part 6) ❑ General Purpose Committee 0 Sponsored M Primarily Formed Candidate/ 0 Small Contributor Committee Officeholder Committee 0 Political Party/Central Committee (Also Complete Part 7) 3. Committee Information I.D. NUMBER I i �3 Li I"7)0 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 CODEIPHONE Date of election If applicable: (Month, Day, Year) Date Stamp V Page I of For Official Use Only 11/8/2011 2. Type of Statement: Preelection Statement E] Quarterly Statement r__j Semi-annual Statement F] Special Odd -Year Report n Termination Statement n Supplemental Preelection (Also file a Form 410 Termination) Statement - Attach Form 495 n Amendment (Explain below) Treasurer(s) NAME OF TREASURER Darren Sargent 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 4. Verification 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 — By Datei SigreofTreasurerorAssistant, asurer Executed on — By Date '-Sonature of Co-&oNN OfItoehokfer. Candidate,oate Measure Proponent or Responsible Officer of Sponsor Executed on By Date Signature of Controlling 0fruoetx�tder, Candidate State Measure Proponent Executed on Date By Signature of Controlling Officeholder. Candidate, State Measure Proponent FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 8661ASK-FPPC (866/2754772) State of California Type or print in ink. Recipient Committee Campaign Statement 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. COMM117EENAME 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.Q. BOX) CITY STATE ZIP CODE AREA CODE/PHONE 6. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE COVER PAGE - PART 2 Page 2 of BALLOT NO. OR LETTER JURISDICTION I F1SUPPORT ❑ 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 candidate(s) 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 Toil -Free Helpline: 8661ASK-FPPC (8661275-3772) State of Cailfomla Campaign Disclosure Statement Type or print in ink. SUMMARY PAGE Amounts may be rounded Statementp erlod Summary Page to whole dollars. W!,, from -' /I Expenditures Made 6. Payments Made ....................................................... through q12y III _Page of SEE INSTRUCTIONS ON REVERSE .... ...... Schedule H, Line 3 0 8. SUBTOTAL CASH PAYMENTS ............. ........ .... Add Lines 6 + 7 $ 3279.73 $ 9. Accrued Expenses (Unpaid Bills) ............................... NAME OF FILER 0 10. Nonmonetary Adjustment .......................................... Schedule C, Line 3 0 I.D. NUMBER <� � k, m ci VVI ci V1 , 3279.73 $ / ;� (-/ / 3 cl�- Contributions Received ColumnA Column B Calendar Year Summary for Candidates TOTALTHISPERIOD (FROM ATTACHED SCHEDULES) CALENDARYEAR TOTALTODATE Running in Both the State Primary and General Elections 1. Monetary Contributions ..... ........................ ............ Schedule A, Line 3 $ 5416.20 $ 5416.20 0 0 1/1 through 6/30 7/1 to Date 2. Loans Received ...................................................... Schedule B, Line 3 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1 + 2 $ 5416.20 $ 5416.20 20. Contributions Received $ $ 4. Nonmonetary Contributions .................................... Schedule C, Line 3 2180.00 2180.00 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED ........................... Add Lines 3 + 4 $ 7596.20 $ 7596.20 Made $ $ Expenditures Made 6. Payments Made ....................................................... Schedule E, Line 4 $ 3279.73 $ 7. Loans Made . ............ .......... ................... .... ...... Schedule H, Line 3 0 8. SUBTOTAL CASH PAYMENTS ............. ........ .... Add Lines 6 + 7 $ 3279.73 $ 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 $ 3279.73 $ 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 1, 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. 17. LOAN GUARANTEES RECEIVED ....... .... ........ Schedule B, Part 2 $ Cash Equivalents and Outstanding Debts 18. Cash Equivalents . ............. ........... , see instructions on reverse $ 19. Outstanding Debts ......... .... Add Line 2 + Line 9 in Column 8 above $ 0 5416.20 0 3279.73 2136.47 I I 3279.73 0 3279.73 0 0 3279.73 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). Expenditure 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 (866/276-3772) Schedule A Type or print In Ink. SCHEDULE A MonetaContributions Received Amounts may be rounaea ry dollars. Statement co-Ofr`�',�6eriod I CALIFORNIA to whole 460 from FORM y IZF4 SEE INSTRUCTIONS ON REVERSE h througb Page Of NAME OF FILER I.D. NUMBER /' DATE FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER AMOUNT RECEIVED THIS CUMULATIVE TO DATE CALENDAR YEAR PER ELECTION TO DATE RECEIVED (IFCOMMrrTEE, ALSOENTER I.D. NUMBER) CODE (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. I -DEC. 31) (IF REQUIRED) OF BUSINESS) 08/31/11 Darren Sargent ®IND RCOM Software manager 1000.00 tz' San Rafae, A 94901 MOTH F-1 PTY r-ISCC Dick and Jane Zeit ®IND F�Com Retired 09/01/11 100.00 200.00 S aTa@17N 94901 F-JOTHF-1 PTY MSCC Amy Likeover ®IND FICOM Retired 09/02/11 100.00 100.00 SV"a "ae,Mal MOTH M PTY Fj sce Paulanne Pritchard ®IND 09/02/11 F1COM 25.00 25.00 a a 4901 [:] OTH F-1 PTY M SCC Dottie Cichon ®IND Retired 09/06/11 '1 EICOM 2000.00 2000.00 Wawf"MT,a 94901 Ej OTH 17� PTY EISCC SUBTOTAL$ 3225.00 Schedule A Summary 1. Amount received this period - itemized monetary contributions, (include all Schedule A subtotals) .. ........ ..................... ............... ......... ........ ...... $ L '2-o 2. Amount received this period - unitemized monetary contributions of less than $100 ............................. $ 3. Total monetary contributions received this period. (Add Lines I 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 A (Continuation Sheet) Type or print in Ink. SCHEDULE A (CONT) Monetary Contributions Received Amounts may be rounded Statementco d A to whole dollars. from through,.--- Of NAME OFFILER I. D. NUMBER 130 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 OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE (IF SELF-EMPLOYED, ENTER NAME PERIOD (JW I -DEC. 31) (IF REQUIRED) FBUSINESS) Dick and Jane Zeit ®IND Retired 09/24/11 _;am-hmwmonlgk EICOM 100.00 200.00 9WRMWRfflffi,U0a 94901 []OTH n PTY r-1 SCC Kevin Stockman ®IND Self Employed, Marin 09/24/11 [-]COM Nature adventures 100.00 100.00 lfflkel, Ca 94901 F-1 OTH PTY ❑ SCC Phil Cichon ®IND Retired 09/24/11Fl O 500.00 500.00 4 E]COTHM El PTY M SCC Samantha Sargent JZIND -ICOM Self employed, B Street 09/07/11 r Builders 316.20 349.20 99n"TFaTa=ei,a 94901 E]OTH El PTY EISGC ❑IND FJCOM F-JOTH ❑ PTY [:]SCC *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 SUBTOTAL$ 1016.20 FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/276-3772) Schedule A (Continuation Sheet) Type or print In ink. I SCHEDULE A (CONT) Monetary Contributions Received Amounts may be rounded statement c W_r_1o_dW, 1 towholedollars. M11 CALIFONIA R .III 4601 from - FORM through 912 page � of NAME OF FILER I.D. NUMBER _3 DATE FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER AMOUNT RECEIVED THIS CUMULATIVE TO DATE CALENDAR YEAR PER ELECTION TO DATE RECEIVED (IF COMMITTEE, ALSO ENTER I.D. NUMBER) CODE (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. I -DEC. 31) (IF REQUIRED) OF BUSINESS) Marin Builders Association BAPAG F-JIND 09/23/11 9 ocom 500.00 500.00 MOTH M PTY MSCC Darren Sar ent ®IND Sr. Software Manager, 08/17/11 mcom TVworks 357.00 1357.00 a 94901 MOTH M PTY E1SCC MIND mcom MOTH M PTY MScC [:] IND mcom M OTH E] PTY F1 scc MIND mcom MOTH M PTY E] SCC *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 SUBTOTAL$ 857.00 FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/276-3772) Schedule C Type or print in Ink. J .qrHFni ILE C Amounm may Ve rounueu Nonmonetary Contributions Received to whole dollars. Statement pe od CALIFORNIA A from, FORM -v60 !�2_!Z SEE INSTRUCTIONS ON REVERSE through Page OfZ NAME OF FILER I.D. NUMBER I --I DATE FULL NAME, STREET ADDRESS AND CONTRIBUTOR IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER DESCRIPTION OF AMOUNT/ FAIR MARKET CUMULATIVE TO DATE PER ELECTION TO DATE RECEIVED ZIP CODE OF CONTRIBUTOR (IF COMMITTEE, ALSO ENTER LID, NUMBER) CODE (IF SELF-EMPLOYED, ENTER NAME OF BUSINESS) GOODS OR SERVICES VALUE CALENDAR YEAR (JAN I - DEC 31) (IF REQUIRED) Donato LaMorte ®IND self employed/owner gift certificates 09/14/111 1 11051161e,CA F1COM Napoli Pizza 80.00 80.00 94901 ❑OTH F-1 PTY EISCC Erik and Tessa Dilinger ®IND Graphic Producer, Entertainment for 09/24/11 2swumiLummiL F_1C0M Lucas Films, Art Fundraiser 100.00 1100.00 §ffffffffft1f,Tft 94901 FJOTH Therapy instructor, r-1 P-ry Cedars of Marin E]SCC Erik„' ' ' qer ®IND Graphic Producer, Graphic Design 09/05/11 MCOM Lucas Films 1000.00 1100.00 Ca 94901 F-JOTH ❑PTY FJSCC Darrent Sargent JOIND Sr. Software Manager, Web Site 09/05/11 --mmomman— OCOM TVworks Development 1000.00 2357.00 S n" afael, Ca 94901 FJOTH ❑PTY F-1SCC Attach additional information on appropriately labeled continuation sheets. SUBTOTAL $ 2180.00 1 Schedule C Summary 1. Amount received this period — itemized nonmonetary contributions. (include all Schedule C subtotals.) ............... .......... ................. .............. ......... ...... ............ ....... $ 2. Amount received this period — unitemized nonmonetary contributions of less than $100 ........................ $ I 3. Total nonmonetary contributions received this period. 2180.00 (Add Lines I and 2. Enter here and on the Summary Page, Column A, Lines 4 and 10.) .... ...... ..... 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 Payments Made SEE INSTRUCTIONS ON REVERSE NAME OF FILER Type or print in ink. Amounts may be rounded to whole dollars. Statement cool 'Perlod from 12 through Page of 1.D. NUMBER CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CNP campaign paraphernalia/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 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 I.D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID City of San Rafael 1400 Fifth Ave, San Rafael, Ca 94901 Filing fee FIL 357.00 Dotty LeMieux, Green Dog campaigns, 8 Willow Ave, San Rafael, Ca 94901Consulting fees CNS 2240.00 Strahm Communications, 3000 Kerner Blvd, San Rafael, Ca 94901Remittance Envelopes LIT 333.53 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 2930.53 Schedule E Summary 1. Itemized payments made this period. (Include all Schedule E subtotals.).............................................................................................................. $ 2. Unitemized 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.) ............................. TOTAL $ 3246.73 33.00 0 3279.73 FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) Schedule E CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID I SCHEDULE E (CONT) (Continuation Sheet) Type or print in ink. Amounts may be rounded Statement cov . _��a CALIFORNIA 460 Payments Made to whole dollars. from. FORM SEE INSTRUCTIONS ON REVERSE NAME OF FILER LD. NUMBER CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. {IVP MBR member communications RAD radio airtime and production costs CNG campaign consultants K0G meetings and appearances RR] returned contributions [JB contribution (explain nonmonetary)° OFC offioo expenses SAL campaign workers' aolahnu (VC civic donations PET petition circulating TEL Lx or cable airtime and production costs RL candidate fi|ing/boUotfeeo PHO phone banks TRC candidate travel, lodging, and meals FND fundraising events POL polling and survey nsaeooh TRS staff/spoueetmve|. |odging, and meals IND independent expenditure supporting/opposing others (explain)* POS poouuge, delivery and messenger services TSF transfer between committees of the eomn candidate/sponsor LEG |ogo| defense PRO professional services (legal, accounting) VDT voter registration UT campaign literature and mailings FRT print ads VVEB information technology costs VnV*met.e-maiV NAME AND ADDRESS OF PAYEE (IF COMMIT7EE, ALSO ENTER I.Dr NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID Scan Art, 1259 Park Ave, Emeryville, CA 94608 LIT Walk piece printing 316.20 °Payments that are contributions mindependent expenditures must also be summarized on Schedule D. SUBTOTAL $ 316.20 FPPC Form 460 (January/05) FPPC Toll -Free Helpline: V66KASK-FPPC (866/275-3772)