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Form 460- Rachel Kertz for City Council 2020 (2021-12-31)Recipient Committee COVER PAGE Campaign Statement D [ �/f [; �' • 1 Cover Page (Government Code Sections 84200-4216.5) SEE INSTRUCTIONS ON REVERSE Statement covers period from 07/01/2021 through 12/31/2021 _ 1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4. ❑X Officeholder, Candidate Controlled Committee ❑ Primarily Formed Ballot Measure 0 State Candidate Election Committee Committee 0 Recall 0 Controlled (Also CompelePad 5) 0 Sponsored (Also compere Pae 6) ❑ General Purpose Committee 0 Sponsored 0 Small Contributor Committee 0 Political Party/Central Committee ❑ Primarily Formed Candidate/ Officeholder Committee (Also Complete Pad 7) 3. Committee Information I.D. NUMBER 1427074 COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) Rachel Kertz for City Council 2020 STREET ADDRESS (NO P.O. 80X) CITY STATE ZIP CODE AREA CODE/PHONE Antelope CA 95843 ( MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL: FAX / E-MAIL ADDRESS ( Date of election if appal (Month, Day, Year) J A N 3 1 2022 1 Of 9 For Official Use Only 11/03/2x20 ff CLERK'S OFFI E 2. Type of Statement: ❑ Preelection Statement ❑ Quarterly Statement ❑X Semi-annual Statement ❑ Special Odd -Year Report ❑ Terminafion Statement ❑ Supplemental Preelection (Also file a Form 410 Termination) Statement - Attach Form 495 ❑ Amendment (Explain below) Treasurer(s) NAME OF TREASURER Chelsea Johnson MAILING ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE Antelope CA 95843 ( 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 Executed on 01/21/2022 By Date Executed on 01/21/2022 By Date Executed on Date Executed on Data By Signalise oFCorrholling Officeholder, Candidate, Slate Measue Proponent By signature ofCantroningotficeholder,Ca,amte,SrateMeasure Proponent FPPC Form 460 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (8661275-3772) www.fppc.ca.gov Recipient Committee Campaign Statement Cover Page — Part 2 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Rachel Kertz OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) City Council Member City of San Rafael District 4 RESIDENTIAL/BUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP San Rafael CA 94903 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) CITY STATE ZIP CODE AREA CODE/PHONE www.neffile.com COVER PAGE - PART 2 Page 2 of 9 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 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 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Campaign Disclosure Statement SUMMARYPAGE Amounts may be rounded Statement covers period • - Summary Page to whole dollars. _ A1041 ' from 071o1/2021 • SEE INSTRUCTIONS ON REVERSE NAME OF FILER Rachel Kertz for City Council 2020 Contributions Received ColumnA TOTALTHIS PERIOD (FROMATTACHED SCHEDULES) 1. Monetary Contributions ........................................... Schedule A, Line 3 $ 100.00 7. Loans Made............................................................. 2. Loans Received...................................................... Schedule B, Line 3 Add Lines 6+7 0.00 Schedule F Line 3 3. SUBTOTAL CASH CONTRIBUTIONS ....... ............ Add Lines 1 +2 $ 100.00 4. Nonmonetary Contributions ...................... :............. Schedule C, Line 3 0.00 5. TOTAL CONTRIBUTIONS RECEIVED .......... :..•.:.-..---•... Add Lines 3+4 $ 100.00 Expenditures Made 6. Payments Made ....................................................... Schedule E, Line 4 7. Loans Made............................................................. Schedule H, Line 3 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6+7 9. Accrued Expenses (Unpaid Bills) ............................... Schedule F Line 3 10. Nonmonetary Adjustment .......................................... Schedule C, Line 3 11. TOTAL EXPENDITURES MADE ................................ AddLines8+9+10 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. $ 365.44 0.00 $ 365.44 0.00 0.00 $ 365.44 $ 1,425.71 100.00 0.00 365.44 $ 1.160.27 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 www.netfile.com 0.00 $ 0.00 $ 16,221.75 through 12/31/2021 Page 3 of 9 I.D. NUMBER Column B CALENDARYEAR TOTALTO DATE $ 250.00 16,000.00 $ 16,250.00 0.00 $ 16,250.00 $ 10,196.12 0.00 $ 10,196.12 221.75 0.00 $ 10,417.67 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). 1427074 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 Subject to Voluntary Expenditure Limit) Date of Election Total to Date (mm/dd/yy) 1 1 $ *Amounts in this section may be different from amounts reported in Column B. FPPC Form 460 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (8661275-3772) www.fppc.ca.gov &ZIM : R1 r7l1 SCHEDULE A Amounts may be rounded Monetary Contributions Received to whole dollars. Statement covers period oil 1 ' from 07/01/2021 ` through 12/31/2021 Page 4 of 9 SEE INSTRUCTIONS ON REVERSE NAME OF FILER I.D. NUMBER Rachel Kertz for City Council 2020 1427074 DATE AND ZIPDEO 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 (EI F COMMITTEE, ALSO I.D.N CODE * (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. 1 - DEC. 31) (IF REQUIRED) OF BUSINESS) 07/30/2021 Ray Lorber MIND Retired 100.00 100.00 ❑COM n/a Sari Rafael, CA 94903 OTH tkeceived through inte iary% E] Democracy Engine, LLC ❑ PTY 2125 14th Street, NW, rite 101 West Washington, DC 20009 ❑ SCC ❑IND [-]Com ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑COM ❑ OTH ❑ PTY ❑ SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑ SCC [:]IND ❑ COM ❑ OTH ❑ PTY ❑ SCC Schedule A Summary Amount received this period — itemized monetary contributions. (Include all Schedule A subtotals.) ............................................ SUBTOTAL$ 100.00 1 $ 100.00 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 $ www.netfile.com 0.00 100.00 '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 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov SCHEDULEB-PART1 Schedule B — Part 1 Amounts may be rounded Statement covers period CALIFORNIA Loans Received to whole dollars. FORM . 460 from through 12/31/2021 Page 5 of 9 SEE INSTRUCTIONS ON REVERSE NAME OF FILER I.D. NUMBER Rachel Kertz for City Council 2020 1427074 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL, ENTER tai OUTSTANDING I°) AMOUNT (c) AMOUNT PAID (d) OUTSTANDING (e) INTEREST (f) ORIGINAL (91 CUMULATIVE OF LENDER OCCUPATION AND EMPLOYER BALANCE RECEIVED THIS OR FORGIVEN gALANCEAT PAID THIS AMOUNT OF CONTRIBUTIONS (IF COMMITTEE, ALSO ENTER I.D.NUMBER) (IFSELF-EMPLOYED,ENTER NAMEOFBUSINESS) BEGINNING THIS PERIOD PERIOD THIS PERIOD" CLOSE OF THIS PEED PERIOD LOAN TO DATE Rachel Kertz Candidate ❑ PAID CALENDARYEAR Candidate San Rafael, CA 94903 $ 0.00 $ 6,000.00 0.00% $ 6.000.00 $ 10.000.00 ❑ FORGIVEN PERELECTION" RATE $ 6.000.00 $ 0.00 $ n.00 06/18/2021 $ 0.00 12/18/2020 $ DATE DUE t© IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE INCURRED Rachel Kertz Candidate ❑ PAID CALENDARYEAR Candidate San Rafael, CA 94903 $ n nn $ in 000.00 n_on/ $ in,onn.00 $ in nnn_nn ❑ FORGIVEN RATE PER ELECTION "* $ 10.000.00 $ 0.00 $ n.nn 07/22/2021 $ n no 01/22/2021 $ DATE DUE tEl IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE INCURRED ❑ PAID CALENDAR YEAR ❑ FORGIVEN PER ELECTION** RATE $ $ $ $ $ DATE DUE to IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE INCURRED SUBTOTALS $ 0.00$ 0.00$ 16,000.00$ 0.00 Schedule B Summary 1. Loans received this period.........................................................:...:.......................... •:.:.:................... $ 0.00 (Total Column (b) plus unitemized loans of less than $100.) 2. Loans paid or forgiven this period ,,,,,,,„,,,,,,,,.,,,,................. $ 0.00 (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 $ 0.00 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. www.netfile.com 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 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov E Schedule E I statement covers period CALIFORNIA Amounts may be rounded ! � Payments Made to whole dollars. from 07/01/2021 "' ILI SEE INSTRUCTIONS ON REVERSE through 12/31/2021 page 6 of 9 NAME OF FILER I.D. NUMBER Rachel Kertz for City Council 2020 1427074 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 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 CJ & Associates, Inc. PRO 35.00 Antelope, CA 95843 CJ & Associates, Inc. I PRO I U 186.14 Antelope, CA 95843 CJ & Associates, Inc. I PRO 1 I 35.00 Antelope, CA 95843 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 256.14 Schedule E Summary 1. Itemized payments made this period. Include all Schedule E subtotals. ........... $ 361.14 2. Unitemized payments made this period of under $100........................................................................................................................................ $ 4.30 3. Total interest paid this period on loans. (Enter amount from Schedule B, Part 1, Column (e).) ............. $ 0.00 4. Total payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.) ............................. TOTAL $ 365.44 FPPC Form 460 (Jan/2016) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) www.fppc.ca.gov www.netfile.com Schedule E (Continuation Sheet) Payments Made Amounts may be rounded to whole dollars. Statement covers period from 07/01/2021 SCHEDULE E SEE INSTRUCTIONS ON REVERSE NAME OF FILER CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID through 12/31/2021 page 7 of 9 I.D. NUMBER Rachel Kertz for City Council 2020 Antelope, CA 95843 CJ & Associates, Inc. PRO 35.00 Antelope, CA 95843 CJ & Associates, Inc. PRO 35.00 Antelope, CA 95843 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. www.neffile.com SUBTOTAL $ 105.00 FPPC Form 460 (Jan/2016) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) www.fppc.ca.gov Schedule F Amounts may be rounded Accrued Expenses (Unpaid Bills) to whole dollars. SEE INSTRUCTIONS ON REVERSE NAME OF FILER Statement covers period from 07/01/2021 through 12/31/2021 SCHEDULEF Page__2__ of 9 I.D. NUMBER Rachel Kertz for City Council 2020 CODE OR DESCRIPTION OF PAYMENT (a) OUTSTANDING BALANCE BEGINNING OF THIS PERIOD (b) AMOUNTINCURRED THIS PERIOD (c) AMOUNTPAID THIS PERIOD (ALSO REPORT ON E) 11427074 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 FIND 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 CREDITOR (IF COMMITTEE, ALSO ENTER I -D- NUMBER) CODE OR DESCRIPTION OF PAYMENT (a) OUTSTANDING BALANCE BEGINNING OF THIS PERIOD (b) AMOUNTINCURRED THIS PERIOD (c) AMOUNTPAID THIS PERIOD (ALSO REPORT ON E) (d) OUTSTANDING BALANCE AT CLOSE OF THIS PERIOD CJ & Associates, Inc. PRO 35.00 0.00 35.00 0.00 Antelope, CA 95843 CJ & Associates, Inc. PRO 0.00 3S.001 0.00 35.00 Antelope, CA 95843 Loren Kertz OFC 43.00 0.00 0.00 43.00 San Rafael, CA 94903 * Payments that are contributions or independent expenditures must also be .,moo r e�tio.r,ao In SUBTOTALS$ Schedule F Summary 1. Total accrued expenses incurred this period. (Include all Schedule F, Column (b) subtotals for accrued expenses of $100 or more, plus total unitemized accrued expenses under $100.)...... 78.00$ 35.00$ 35.00$ 78.00 2. Total accrued expenses paid this period. (Include all Schedule F, Column (c) subtotals for payments on accrued expenses of $100 or more, plus total unitemized payments on accrued expenses under $100.), 3. Net change this period. (Subtract Line 2 from Line 1. Enter the difference here and on the Summary Page, Column A, Line 9.)................................................................................................ www.netfile.com INCURRED TOTALS $ 35.00 PAID TOTALS $ 35.00 ........... .......... I......................... NET $ 0.00 May be a negatIve number FPPC Form 460 (Jan/2016) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) www.fppc.ca.gov Schedule F (Continuation Sheet) Amounts may rounded Statement covers period to whole dollars. Accrued Expenses (Unpaid Bills) from 07/01/2021 through 12/31/2021 NAME OF FILER Rachel Kertz for City Council 2020 SCHEDULE F (CONT.) Page 9 of 9 I.D. NUMBER 1427074 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 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. NAME AND ADDRESS OF CREDITOR (IF COMMITTEE, ALSO ENTER I.D. NUMBER) CODE OR DESCRIPTION OF PAYMENT t OUTSTAo NDING BALANCE BEGINNING OF THIS PERIOD ( AMOUNTIN CURRED THIS PERIOD (c) AMOUNT PAID THIS PERIOD (ALSO REPORT ON E) ( OUTSTANDING BALANCE AT CLOSE OF THIS PERIOD Loren Kertz San Rafael, CA 94903 WEB 143.75 0.00 0.00 143.75 www.netfile.com SUBTOTALS $ 143.75$ 0.00$ 0.00 $ 143.75 FPPC Form 460 (Jan/2016) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) www.fppc.ca.gov