HomeMy WebLinkAboutForm 460 - Maribeth Bushey for City Council 2017 (2016-06-30) AmendmentRecipient Committee
Campaign Statement
Cover Page
Statement covers period
January 1, 2016 from _____ -"--'-__ _
SEE INSTRUCTIONS ON REVERSE June 30 , 2016 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 CompJet. Part 5)
o General Purpose Committee o Sponsored o Small Contributor Committee o Political Party/Central Committee
o Controlled o Sponsored
(Also Ccmpl.le Pillt 6)
o Primarily Formed Candidate/
Officeholder Committee
(Also Complete 1'811 7)
1.0. NUMBER
1358370
Maribeth Bushey for San Rafael City Council 2017
STREET ADDRESS (NO P.O. BOX)
CITY
San Rafael
STATE ZIP CODE
CA 94901
MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX
CITY
OPTIONAL: FAX I E-MAIL ADDRESS
STATE ZIP CODE
AREA CODE/PHONE
(
AREA CODE/PHONE
4. Verification
I have used all reasonable diligence in preparing and reviewing this statement and to the b
certify under penalty of perjury under the laws of the State of California that the foregoing'
Executed on __ S_e:.,.pt_e_m....,b ... e..,.r_5-:...., 2_0_1_6 __ _
Date ~f;d4/fe Executed on
Date of election If apl)lIcabl<sl
(Month, Day, Year)
ellY CLERK'S 0
2. Type of Statement:
o Preelection Statement
fIii3 Semi-annual Statement o Termination Statement
(Also file a Form 410 Termination)
~ Amendment (Explain below)
To correct reported amounts
Treasurer(s)
NAME OF TREASURER
Mark Kyle
MAILING ADDRESS
CITY
San Rafael
NAME OF ASSISTANT TREASURER, IF ANY
MAILING ADDRESS
CITY
OPTIONAL: FAX I E-MAIL ADDRESS
o Quarterly Statement o Special Odd-Year Report
STATE ZIP CODE AREA CODEJPHONE
CA 94901 (
STATE ZIP CODE AREA CODE/PHONE
c ntained herein and in the attached schedules is true and complete. I
Executed on -----""Oa.,.,.te------By _____ ~~~~~~~~~~~~~~~~~~-----Signalure 0/ Controlling Officeholder, Candidate, State Measure Proponenl
Executed on-----""oa-.te------By _____ ~~~~~~~~~~~~~~~~~~-----Signature 0/ Controlling Officeholder, Candidate , State Measure Proponent
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3172)
www.fppc.ca.gov
Recipient Committee
Campaign Statement
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)
San Rafael City Council
RESIDENTIAUBUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP
1400 Fifth Avenue 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.
COMMmEE NAME 1.0. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE?
DYES ONO
COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
COMMITTEE NAME I.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE?
DYES ONO
COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
COVER PAGE -PART 2
6. Primarily Formed Ballot Measure Committee
NAME OF BALLOT MEASURE
BALLOT NO. OR LETTER JURISDICTION o SUPPORT o 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 Ust names of
offlceholder(s) or candldate(s) for which this committee Is primarily formed.
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD o SUPPORT o OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD o SUPPORT o OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD o SUPPORT o OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD o SUPPORT o OPPOSE
Attach continuation sheets If necessary
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Campaign Disclosure Statement
Summary Page
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
Maribeth Bushey for San Rafael City Council 2017
Contributions Received
1. Monetary Contributions.. ................................................. Schedule A, Une 3 $
2. Loans Received ................................................................ Schedule e, Une 3
3. SUBTOTAL CASH CONTRIBUTIONS .............................. Add Unes 1 + 2 $
4. Nonmonetary Contributions............................................ Schedule C, Une 3
5. TOTAL CONTRIBUTIONS RECEIVED ................................... Add Unes 3 + 4 $
Expenditures Made
6. Payments Made...................................................... .......... Schedule E, Une 4 $
7. Loans Made................... ................................. ..... ........ ...... Schedule H, Une 3
8. SUBTOTAL CASH PAyMENTS .......................................... AddUnes6+7 $
9. Accrued Expenses (Unpaid Bills) .......................................... Schedule F, Une 3
10. Nonmonetary Adjustment... ...................................................... Schedule C, Une 3
11. TOTAL EXPENDITURES MADE ........................................ Add Lines 8 + 9 + 10 $
Current Cash Statement
12. Beginning Cash Balance ............................ Previous Summery Pege, LIne 16 $
13. Cash Receipts ........................................................... Column A, LIne 3 above
14. Miscellaneous Increases to Cash .................................. Schedule I, Une 4
15. Cash Payments ......................................................... Column A, LIne 8 above
16. ENDING CASH BALANCE .................. Add LInes 12 + 13 + 14, then subtrect LIne 15 $
If this Is a termination statement, Une 16 must be zero.
17. LOAN GUARANTEES RECEIVED ................................ Schedule e, Part 2 $
Cash Equivalents and Outstanding Debts
18. Cash Equivalents ................................................ SeelnstructlDns on reverse $
19. Outstanding Debts.............................. Add LIne 2 + LIne 9 in Column e abDve $
Amounts may be rounded
to whole dollars.
ColumnA
TOTAL THIS PERIOD
(FROM ATIACHED SCHEDULES)
0.0
$
$
$
SUMMARY PAGE
Statement covers period
January 1, 2016 from ____ -=-~ __ _
CALIFORNIA 460
FORM
3 4 June 30, 2016 through _______ _ Page ___ of __ _
Column B
CALENDAR YEAR
TOTAL TO DATE
0.0
1.0. NUMBER
1358370
Calendar Year Summary for Candidates
Running in Both the State Primary and
General Elections
20. Contributions
Received
21. Expenditures
1/1 through 6/30
$-----
Made $ ____ _
7/1 tD Date
$-----
$-----
346.79 $ 346.79
Expenditure Limit Summary for State
Candidates
346.79
354.25
346.79
7.46
0.0
0.0
$
$ 346.79
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).
22. Cumulative expenditures Made*
(If Subjecllo Voluntery Expenditure Limit)
Date of Election
(mm/dd/yy)
----1----1 __
----1----1 __
Total to Date
$-----
$-----
·Amounts In this section may be different from amounts
reported in Column B.
FPPC Form 460 (Jan/20I6)
FPPC Advice: advlce@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
January 1, 2016 from ___ --=:....-..:....-. __ _
CALIFORNIA 460
FORM
SEE INSTRUCTIONS ON REVERSE through June 30, 2016 Page _4 __ of_4 __
NAME OF FILER 1.0. NUMBER
Maribeth Bushey for San Rafael City Council 2017 1358370
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 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 fund raising 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 Oegal, 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
Mark Kyle Reimburse Secreatary of State Filing Fee
SOS 50.0
Peter Reiks Web site fees reimbursed to web master
Web 296.79
* Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $
Schedule E Summary
346.79 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 $ _____ _
FPPC Form 460 (Jan/2016)
FPPC Advice: advlce@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov