HomeMy WebLinkAboutForm 460 - Maribeth Bushey for City Council 2017 (2016-12-31)Recipient Committee
Cam paign Statement
Cover Page
SEE INSTRUCTIONS ON REVERSE
Statement covers period
from ___ Ju_I!....Y _1 ~, 2_0_1_6 __
December 31, 2016 through ________ _
1. Type of Recipient Committee: AIlCommlltees-CompletB Parts 1, 2, 3, and 4.
~ Officeholder, Candidate Controlled Committee o State Candidate Election Committee o Recall
(AJso Campl.r. Pm 5)
o General Purpose Committee o Sponsored o Small Contributor Committee o Political Party/Central Committee
3. Committee Information
(OR NAME IF
o Primarily Formed 8allot Measure
Committee o Controlled o Sponsored
(AJso Campier. P.t 6)
o Primarily Formed Candidate/
Officeholder Committee
(Abo co",,"" Pm 7}
1.0 , NUMBER
1358370
Maribeth Bushey for San Rafael City Counil 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 STATE
OPTIONAL. FAX I E·MAILADDRESS
maribeth@maribethmaribeth4sanrafael.org
4. Verification
ZIP CODE
AREA CODE/PHONE
(
AREA CODEIPHONE
Date of election If apl3licttblle:
(Month, Day, Year)
November7,201~~r---------------~--~
2. Type of Statement:
o Preelection Statement
Ii2I Semi-annual Statement o Termination Statement
(Also file a Form 410 Termination)
o Amendment (Explain below)
Treasurer(s)
NAME OF TREASURER
Mark Kyle
MAILING ADDRESS
25 Cottonwood
CITY
San Rafael
NAME OF ASSI STANT TREASURER, IF ANY
MAILING ADDRESS
CITY
OPTIONAL. FAX / E·MAIL ADDRESS
o Quarterly Statement
o Special Odd-Year Report
STATE ZIP CODE AREA CODE/PHONE
CA 94901 (
STATE ZJPCODE AREA CODE/PHONE
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.
certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Executed on ------:D""a"'"te-------
Executed on ____ J_a_n_u_a_r-.:;y:::;3::--1;,... 2_0_1_6 __ _
Oate
Executed on -----'D::;:a:;:le:--------
Executed on ------:0""8"'"te-------
By ________________ ~~~~~~~~~~~~------------
By---------~s-,gn~a~tur~e-.or~C~oo~tro~lb~ng-.o~rfi~lc.~h~O~::-~~,C~a~nd~;d~at~e,~SI~at~e~Me~a~su~ffi~P~ro~po~ne~nt~---------
By ------,S~ig:::n~at:-::ur::-e o:::;f""Co==n~tro:::lIl~ng::-;O"'ff;:::ic==eh:=;ol:::de::-r."C==an~dl:=:da:;:te~. S""ta:::t.::-;M:;:e:=as~ure=nP=ro==po:=ne::n::-, -------
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
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 Ave San Rafael CA 94901
Related Committees Not Included in this Statement: Ustanycommittees
not included in this statement that are controlled by you or are primarily formed to receive
contributions or make elCpenditures on behalf of your candidacy.
COMMITTEE NAME 1.0 NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE?
DYES o NO
COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
COMMITTEE NAME 1.0. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE?
DYES o NO
COMMITTEE ADDRESS STREET ADDRESS (NO P.O . BOX)
CITY STATE ZIP CODE AREA CODEIPHONE
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
officeholder(s) or candidate(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: advlce@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Campaign Disclosure Statement
Summary Page
Amounts may be rounded
to whole dollars.
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
ColumnA Contributions Received TOTAL THIS PERIOD
(FROM ATTACHED SCHEDULES)
1. Monetary Contributions ... ................................................ Schedule A. Lme 3 $
2. Loans Received................................................................ Schedule B, Line 3
3 . SUBTOTAL CASH CONTRIBUTIONS .............................. Add Lines 1 + 2 $
4. Nonmonetary Contributions.............. .............................. Schedule C. Line 3
5. TOTAL CONTRIBUTIONS RECEIVED ................................... Add Lines 3 + 4 $ 0.0
Expenditures Made
6. Payments Made................................................................ Schedule E. Line 4 $
7. Loans Made ....................................................................... Schedule H, Line 3
8. SUBTOTAL CASH PAyMENTS .......................................... AddLines6+7 $
9. Accrued Expenses (Unpaid Bills) ..................................... Schedule F. Line 3
10. Nonmonetary Adjustment.. .................................................... Schedule C, Line 3
11 . TOTAL EXPENDITURES MADE ........................................ Add Lines 8 + 9 + 10 $ 0.0
Current Cash Statement
12. Beginning Cash Balance ............................ Previous Summary Page. Line 16 $ 7.46
13 . Cash Receipts ........................................................... Column A. Lme 3 above
14. Miscellaneous Increases to Cash ............. :.................... Schedule I. Line 4
15. Cash Payments ......................... ................................ Column A, Line 8 above
16 . ENDING CASH BALANCE .................. Add Lmes 12 + 13 + 14. Ihensub/rBctLine 15 $ 7.46
If this is a termination statement, Line 16 must be zero.
17 . LOAN GUARANTEES RECEiVED ................................ ScheduleB. Palf2 $ 0.0
Cash Equivalents and Outstanding Debts
18 . Cash Equivalents .............. ........... ....................... See ins/ructions on reverse $ 0.0
19. Outstanding Debts .............................. Add Une 2 + Lme 9 in Column B above $ 0.0
SUMMARY PAGE
Statement covers period CALIFORNIA 460
FORM from ___ J_u_IY_1_, 2_0_1_6 __
3 December 31, 2016 Page 3 of through ------
$
$
$
$
$
s
Column B
CALENDAR YEAR
TOTAl TO DATE
0.0
0.0
To calculate Column 8,
add amounts In Column
A to the corresponding
amounts from Column 8
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).
1.0 . NUMBER
1358370
Calendar Year Summary for Candidates
Running in Both the State Primary and
General Elections
1/1 through 6/30 7/1 to Date
20. Contributions
Received $ _____ _ $ ____ _
21. Expenditures
Made $ _____ _ $_----
Expenditure Limit Summary for State
Candidates
22. Cumulative Expenditures Made·
(If Sublecllo Voluntary Expenditure limit)
Date of Election
(mm/dd/yy)
-----1----' __
Total to Date
$-----
$-----
'Amounts in this section may be different from amounts
reported in Column 8 .
FPPC Form 460 (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov