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Home My WebLink AboutForm 460 - Maribeth Bushey-Lang for City Council 2013 (2015-06-30)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 January 1, 2015 through June 30, 2015 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) 0 Sponsored (Also Complete Part 6) F-1General Purpose Committee Q Sponsored Q Small Contributor Committee Q Political Party/Central Committee ❑ Primarily Formed Candidate/ Officeholder Committee (Also Complete Part 7) 3. Committee Information I.D. NUMBER 1358370 COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) Maribeth Bushey Lang for San Rafael City Council 2013 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 COVERPAGE Date of election if applicable: JUL 3 1 2015 Page of.� (Month, Day, Year) Time: For Official Use Only City Clerk's O�fice City of San Rafael 2. Type of Statement: ❑ Preelection Statement ❑ Quarterly Statement ❑ Semi-annual Statement ❑ Special Odd -Year Report ❑ Termination Statement ❑ Supplemental Preelection (Also file a Form 410 Termination) Statement -Attach Form 495 ❑ Amendment (Explain below) Treasurer(s) NAME OF TREASURER Mark Kyle, Esq. MAILING ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE San Rafale CA 94901 NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL: FAX / E-MAIL ADDRESS 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 k ge the inform atio co ' ed rein and in the attached schedules is true and complete. I certify under penalty of perjury under a laws f the State of California that the foregoing is true and correc 7 ( Executed on O By Date i Si nalur rea4ure,,;:sistan1Treasu r 7Eecuted on v ByG/� Date Signature of Controlling Officeholder, Candidate, State Measure Proponent or Wponsible Officer of SponscW Executed on By Date Signature of Controlling Officeholder, Candidate, State Measure Proponent Executed on By Date Signature of Controlling Officeholder, Candidate, State Measure Proponent FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) State of California Recipient Committee Type or print in ink. COVER PAGE - PART 2 CALIFORNIA Campaign Statement • ORM • Cover Page — Part 2 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Maribeth Bushey OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) 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 STREETADDRESS (NO P.O. BOX) Page '�z of 6. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE BALLOT NO. OR LETTER I JURISDICTION I ❑ 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 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 �1 I , 01MIC ur wur Ant^ wurarnurvc Attach continuation sheets if necessary FPPC Form 460 (January/06) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/276-3772) State of California Campaign Disclosure Statement Summary Page Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period from January 1, 2015 SUMMARY PAGE Expenditures Made To calculate Column B, add amounts in Column A to the corresponding amounts 6. Payments Made ....................................................... June 30, 2015 50 $ 50 7. Loans Made............................................................. Schedule H, Line 3 0 through 8. SUBTOTAL CASH PAYMENTS .................................... Page _a__ of SEE INSTRUCTIONS ON REVERSE 50 9. Accrued Expenses (Unpaid Bills Schedule F, Line 3 0 0 10. Nonmonetary Adjustment .......................................... NAME OF FILER 0 0 11. TOTAL EXPENDITURES MADE ................................Add Lines 6+9+ 10 $ I.D. NUMBER 50 1358370 B Calendar Year Summary for Candidates Contributions Received To Aolu EA CCLolumn Running in Both the State Primary and (FROM ATTACHED SCHEDULES) TOTALTODATE General Elections 1. Monetary Contributions ........................................... Schedule A, Line 3 $ 0 $ 0 0 1/1 through 6/30 7+1 to Date 2. Loans Received...................................................... Schedule a, Line 3 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1 +2 $ 0 $ 0 20. Contributions Received $ $ 4. Nonmonetary Contributions .................................... Schedule C, Line 3 0 0 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED.....••.•••••...••••.•••••• Add Lines 3+4 $ 0 $ 0 Made $ $ Expenditures Made To calculate Column B, add amounts in Column A to the corresponding amounts 6. Payments Made ....................................................... Schedule E, Line 4 $ 50 $ 50 7. Loans Made............................................................. Schedule H, Line 3 0 0 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6 + 7 $ 50 $ 50 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 $ 50 $ 50 Current Cash Statement 12. Beginning Cash Balance ....................... Previous summary Page, Line 16 $ 13. Cash Receipts ................................................... Column A, Line 3above 14. Miscellaneous Increases to Cash ........................... Schedule I, 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 B above $ iF'T•'111V 0 To calculate Column B, add amounts in Column A to the corresponding amounts from Column B of your last 50 report. Some amounts in Column A may be negative figures that should be subtracted from previous /I d 0 - period amounts. If this is _M46-09 the first report being filed 0 for this calendar year, only carry over the amounts from Lines 2, 7, and 9 (if any). C 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 (866/275-3772) Schedule E Payments Made SEE INSTRUCTIONS ON REVERSE NAME OF FILER Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period from January 1, 2015 through June 30, 2015 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment Page of I.D. NUMBER 1358370 SCHEDULE E CHIP 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) * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 50 Schedule E Summary 1. Itemized payments made this period. (Include all Schedule E subtotals.).............................................................................................................. $ 50 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 $ 50 FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)