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Home My WebLink AboutHarper, Matthew - 2010 FPPC Campaign Disclosure Forms For 20 Campaign Disclosure Statement Type or print in ink. SUMMARYPAGE Amounts may be rounded Statement covers period LIIF• - Summary Page to whole dollars. � a from 10/17/2010 ® - SEE INSTRUCTIONS ON REVERSE through 12/31/2010 Page 3 of 23 NAME OF FILER I.D. NUMBER Matthew Harper for City Council 2010 1325962 Column Column B Calendar Year Summary for Candidates Contributions Received TOTALTHISPERIOD CALENDARYEAR (FROM ATTACHED SCHEDULES) TOTALTODATE Running in Both the State Primary and General Elections 1. Monetary Contributions ........................................... schedule A,Line 3 $ 9,459.00 $ 29,653.00 1/1 through 6/30 7/1 to Date 2. Loans Received ...................................................... schedule a,Line 3 125.00 1,685.00 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines l+2 $ 9,S84.00 31,338.00 20. Contributions$ Received $ $ 4. Nonmonetary Contributions.................................... Schedule C,Line 3 0.00 129.29 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED ...........................Add Lines 3+4 $ 9,584.00 $ 31,467.29 Made $ $ Expenditures Made Expenditure Limit Summary for State 6. Payments Made....................................................... schedule E,Line 4 $ 11,959.84 $ 30,181.67 Candidates 7. Loans Made............................................................. schedule H,Line 3 0.00 0.00 22. Cumulative Expenditures Made* 8. SUBTOTALCASH PAYMENTS .................................... Add Lines 6+7 $ 11,959.84 $ 30,181.67 (If Subject to Voluntary Expenditure Limit) 9. Accrued Expenses (Unpaid Bills)...............................schedule F Line 3 -6,814.91 3.53 0.73 Date of Election Total to Date 10.Nonmonetary Adjustment ..........................................ScheduleC,Line 0.00 129.29 (mm/dd/yy) 11. TOTAL EXPENDITURES MADE................................Add Lines 8+9+10 $ 5,144.93 $ 33,841.69 _�_� $ Current Cash Statement $ 12.Beginning Cash Balance....................... Previous summary Page,Line 16 $ 3,841.04 To calculate Column B,add 13.Cash Receipts ................................................... Column A,Line 3 above 9,584.00 amounts in Column A to the corresponding amounts *Amounts in this section may be different from amounts 14. Miscellaneous Increases to Cash........................... Schedule 1,Line 4 455.00 from Column B of your last reported in Column B. 15.Cash Payments............... 11,959.84 report. Some amounts in Column A,Line a above Column A may be negative 16.ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ 1,920.20 figures that should be subtracted from previous if this is a termination statement, Line 16 must be zero. period amounts. If this is the first report being filed 17. LOAN GUARANTEES RECEIVED ........................... schedule B,Part 2 $ 0.00 for this calendar year, only carry over the amounts Cash Equivalents and Outstanding Debts from Lines 2, 7, and 9(if 0.00 any). 18. Cash Equivalents........................................ See instructions on reverse $ 19. Outstanding Debts......................... Add Line 2+Line 9 in Column B above $ 5,215.73 FPPC Form 460(January/05) FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772) imp, 'as is A ho" U S. pC)STHG "I",........... PRM f�NT�j ANH f;'; .��Pt MOM, N S' JA lei! WCE UNITEOSTATC -Mom 4 --ow"---- 41�;.:,� ql-'W' --. 92648 WIN' .......... 55 Lugar, Robin From: Lugar Robin Sent: VVedneoday, October 27. 20104:43PK4 To: 'RayLyou@aVinom' Co: Flynn, Joan, Subject: Request for Amendments 0oCYConneU.1Horpe(Oeg|aize and Houston Pre-election _ Statements (7/1/18to9/30/10) Attachments: FPPC Returned Contribution Rwporting.pdf HiLysa, We took your advice and contacted Dixie Howard at the FPPC to inquire about reporting a "name of business" on the 46O Schedule "A" form. Joan and I spoke with Dixie yesterday afternoon by phone, and she concurred that filers must provide a business narne if the contributor code and accompanying box is marked IND and "self," |n regard tnreporting returned contributions, Dixie stated that reporting a negative number on Schedule "A" is acceptable as long as the figure meets criteria identified oo page G-Dof Manual 2 (see aUached). Therefore, our October 2O request to include ename of business in sections of pre-election statements for O'Connell, Harper and Delgleize remains. In addition, please'File an amendment to correct a similar error found on Gabe Huuston's first pre-election statement(8I-01-10to 9'30'10): Schedule A^ Page 4: Include name of business for Cunningham Thank you. Robin From: Flynn, Joan Sent: Wednesday, October Z0, Z01O9:S6P[VI To: .con '; Lugar, Robin* ' Cc: 'Barbana@barbara3O10zonf ' Subject: Re: Request for Amendment to [elgkeizePre-election Statement/7/1/10 to 9/30.. What is really funny is that the clerks say the same thing about different answers from the FPPC! I like the suggestion to talk directly to Dixie-- I have sat in many of her classes over the years, and she knows her stuff. I am taking a few days off(in fact writing this from the nootorhoma riding down the freeway just outside of Indio)since the period tofile as o candidate(write-in)just ended yesterday and with 23 candidates, I am burned out(no offense barbara, but election day cannot come soon enough ---well, maybe you feel the same vvay) Robin, will you try reaching Dixie with the 2 questions- - 1)clarification on the business name for self-employed, and 2)the refundsappearing on schedule A as a negative. Thanks — if you do not reach them, |will try onMonday. Joao `Joan L.L Flynn, �K8C � Huntington Beach City Clerk From: znm < > To: Flynn, loan; Lugar, Robin Cc: Ba 10.com < barbara2010.com> Sent: Wed Oct 2O21:40:l2 2010 Subject: Re: Request for Amendment to Delgleize Pre-election Statemeht(7/1/1O to 9/30... l It is funny because you can call the FPPC and get different answers everytime you call - if you are lucky enough to even get an immediate answer. (It is very frustrating) It all depends on how you ask the question and who you ask the question to. I would call Dixie Howard at the FPPC 916-323-6935 to get the best answers. She is awesome if you can get her I believe the way they are reported is correct and I have been thru many audits with refunds reported like this and they were fine and reported correctly. If we put them on E -then the amounts will not be deducted off the donors total amounts nor the total contributions received for the election. Therefore not giving the public full knowledge on donation amounts. Also Sched E is for expenditures for goods or services I would argue that a refund of a contribution is neither of those. I can change it if you like but it is not done that way anywhere else in the entire state. I will wait to hear back on this from you and then change all the Selfs to the persons name. I hope I do not sound cranky- I am not at all -just exhausted...just finished my last of 85 reports due tomorrow, tonight at 8pm. Lysa Ray Lysa Ray Campaign Services 714-540-2295 714-540-0901 fax www.lysaray.com In a message dated 10/20/2010 8:37:06 P.M. Pacific Daylight Time, iflynn(a-)surfcity-hb.orq writes: Hi Lysa -- I checked with the FPPC today before asking for amendments, and what Robin has told you came directly from the representative on the advice line. If you believe we are wrong. then we can ask for clarification again. I respect your knowledge as I know you file more reports than I see each year, but again this is how we were trained, and had confirmed today via the phone. On the self employed line, again the FPPC said the name of the company is required. For example on one candidate's report, Debbie Cook is listed as self employed and her name is listed under that as her business name. The same way with many of the attorneys and doctors. By doing this it is clear that the business name has not been omitted and clarifies the report for the public. Please let Robin know if you want her to call the FPPC or if you plan to call to clarify the refund. Thanks for your response--Joan Joan L. Flynn, CMC Huntington Beach City Clerk From: RayLysa@aol.com <RayLysa@aol.com> To: Lugar, Robin Cc: Barbaraftarbara2010.com <Barbara(ftarbara2010 com>• Flynn Joan Sent: Wed Oct 20 20:09:37 2010 Subject: Re: Request for Amendment to Delgleize Pre-election Statement(7/1/10 to 9/30 Robin, You are incorrect about refunds being shown on sched E they are to be placed as a negative amount on A It is the proper way to report them as then the final column shows the correct amount for the election cycle (also I use netfile and this is state approved software which fully complies with FPPC laws and requaltions) You are welcome to check with the FPPC or the Secretary of state on this issue. JT Development initially gave$400 and 2 was refunded $151 to equal $249 total contribution - per election column. It is not a mathematical error. The reason it"looks"funny is because it was done in the same filing period. As far as people being self employed - I can give myself as an example- I am a treasurer/self employed. My business name is my name....do you want me to amend all the "self"s to the donors names? Lysa Ray Lysa Ray Campaign Services 714-540-2295 714-540-0901 fax www.lysaray.com In a message dated 10/20/2010 5:33:13 P.M. Pacific Daylight Time. rlugar@surfcity-hb.org writes: Hi Ls The City Clerk has completed review of pre-election statements filed in Huntington Beach on October 5 and requests that you file a 460 Amendment for Delgleize that corrects the following identified errors: Schedule A Page 5: Include name of business for Barbour and Borden Schedule A Page 6: Negative figure (-$250) for BTDJM Phase II Associates, Inc.—refunds should be indicated on Schedule E, not A Schedule A, Page 8: Include name of business for Harlow Schedule A Page 9: Mathematical error—JT Development ($400 and $249???) Schedule A Page 10: Negative figures -$151 for JT Development Co., LLC), and (-$520 for Laguna Board of Directors)—refunds should be indicated on Schedule E, not A Schedule A, Page 16: Include name of business for Thomas Schedule A Page 16: Negative figures -$250 for Theory Properties, LLC)—refunds should be indicated on Schedule E, not.A Schedule A, Page 17: Include name of business for White If you have any questions,please the FPPC at 1-866-275-3772. Robin F.Imf,�r.CMC Assista t City Clerk City of Huntington Beach 2000 Mail) Street Lltintinvton Beach CA 026. 8 €4..5 36:54g5 3 rluga�6tv-hb.or 4 Type or print in ink. SUMMARY PAGE Campaign Disclosure Statement Amounts may be rounded Statement covers period CALIFORNIA Summary Page to whole dollars. 41 from 10/01/2010 FORK SEE INSTRUCTIONS ON REVERSE through 10/16/2010 Page 3 of 12 NAME OF FILER I.D. NUMBER Matthew Harper for City Council 2010 1325962 Column A Column B Calendar Year Summary for Candidates Contributions Received TOTALTHIS PERIOD CALENDARYEAR (FROMATTACHED SCHEDULES) TOTALTO DATE Running in Both the State Primary and General Elections 1. Monetary Contributions ........................................... schedule A,Line 3 $ 3,397.00 $ 20,194.00 1/1 through 6/30 7/1 to Date 2. Loans Received ...................................................... schedule 6,Line 3 0.00 1,560.00 3. SUBTOTALCASH CONTRIBUTIONS ......................... Add Lines 1+2 $ 3,397.00 $ 21,754.00 20. Contributions Received $ $ 4. Nonmonetary Contributions.................................... schedule C,Line 3 0.00 129.29 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED ..•.•......................AddLines3+4 $ 3,397.00 $ 21,883.29 Made $ $ Expenditures Made Expenditure Limit Summary for State 6. Payments Made....................................................... ScheduleE,Line $ 2,013.55 $ 17,912.96 Candidates 7. Loans Made............................................................. Schedule H,Line 3 0.00 0.00 22. Cumulative Expenditures Made* 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6+7 $ 2,013.55 $ 17,912.96 (ItSubjectto Voluntary Expenditure Limit) 9. Accrued Expenses (Unpaid Bills) ...............................Schedule F,Line 3 -608.55 10,345.64 Date of Election Total to Date 10. Nonmonetary Adjustment ..........................................ScheduleC,Line 0.00 129.29 (mm/dd/yy) 11. TOTAL EXPENDITURES MADE................................AddLinesa+9+10 $ 1,405.00 $ 28,387.89 �_� $ Current Cash Statement $ 12. Beginning Cash Balance....................... Previous summary Page,Line 16 $ 2,4S7.59 To calculate Column B,add 13. Cash Receipts ................................................... Column A,Line 3 above 3,397.00 amounts in Column A to the corresponding amounts *Amounts in this section may be different from amounts 14. Miscellaneous Increases to Cash........................... schedule 1,Line 4 0.00 from Column B of your last reported in Column B. 15.Cash Payments.................................................. Column A,Line a above 2,013.55 report. Some amounts in Column A may be negative 16. ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ 3,841.04 figures that should be subtracted from previous if this is a termination statement,Line 16 must be zero. period amounts. If this is the first report being filed 17. LOAN GUARANTEES RECEIVED ........................... schedule s,Part 2 $ 0.00 for this calendar year, only carry over the amounts Cash Equivalents and Outstanding Debts............................. See instructions on reverse $ from lines 2,�,ands(if 18. Cash Equivalents........... 0.00 v 19. Outstanding Debts......................... Add Line 2+Line 9 in Column B above $ 11,905.64 FPPC Form 460(January105) FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772) Lugar, Robin From: Lugar, Robin Sent: Wednesday, October 20, 2010 11:32 AM To: 'RayLysa@aol.com' Cc: Flynn, Joan; 'matthewharper@verizon.net' Subject: Request for Amendment to Harper Pre-election Statement(7/1/10 to 9/30/10) Hi Lysa, The City Clerk has completed review of pre-election statements filed in Huntington Beach on October 5, and requests that you file a 460 Amendment for Matthew Harper that corrects the following identified errors: Schedule A, Page 6: Include name of business for English Schedule A, Page 9: Include name of business for Manuell Schedule A, Page 10: Include name of business for Pedranti Schedule A, Page 12: Include name of business for Sassounian Schedule A, Page 13: Include name of business for Tavoularis If you have any questions, please call the FPPC at 1-866-275-3772. Robin F. Lugar,CMC Assistant City Clerk Cite of Huntington Beach 2€00 Street Iluntit1 ton Beach CA 92648 (;14)53 5401i (/14)374-15xW fzx rlugar(&surfcity-hh.org Apply for passports in the City ClcrVs Office! 1 Campaign Disclosure Statement Type or print in ink. SUMMARY-PAGE Amounts may be rounded Statement covers period Summary Page to whole dollars. s - from 07/01/2010 OORM SEE INSTRUCTIONS ON REVERSE through 09/30/2010 Page 3 of 25 NAME OF FILER I.D. NUMBER Matthew Harper for City Council 2010 1325962 ColumnA Column B Calendar Year Summary for Candidates Contributions Received TOTALTHIS PERIOD CALENDARYEAR Running in Both the State Prima and (FROMATTACHED SCHEDULES) TOTALTODATE g Primary General Elections 1. Monetary Contributions ........................................... Schedule A,Line $ 13,331.00 $ 16,797.00 1/1 through 6/30 7/1 to Date 2. Loans Received ...................................................... Schedule B,Line 3 1,040.00 1,S60.00 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1+2 $ 14,371.00 $ 18,357.00 20. Contributions Received $ $ 4. Nonmonetary Contributions.................................... Schedule C,Line 3 0.00 129.29 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED •.....................••...AddLines3+4 $ 14,371.00 $ 18,486.29 Made $ $ Expenditures Made Expenditure Limit Summary for State 6. Payments Made....................................................... Schedule E,Line 4 $ 15,649.41 $ 15,899.41 Candidates 7. Loans Made............................................................. Schedule H,Line 3 0.00 0.00 22. Cumulative Expenditures Made* 8. SUBTOTALCASH PAYMENTS .................................... Add Lines 6+7 $ 15,649.41 $ 15,899.41 (if Subject to Voluntary Expenditure Limit) 9. Accrued Expenses (Unpaid Bills)...............................Schedule F Line 3 10,801.94 10,954.19 Date of Election Total to Date 10. Nonmonetary Adjustment ..........................................Schedule c,Linea 0.00 129.29 (mm/dd/yy) 11. TOTAL EXPENDITURES MADE................................Add Lines 8+9+10 $ 26,451-35 $ 26,982.89 ,J_J $ Current Cash Statement $ 12. Beginning Cash Balance....................... Previous Summary Page,Line 16 $ 3,736.00 To calculate Column B,add 13.Cash Receipts ................................................... Column A,Line 3 above 14,371.00 amounts in Column A to the corresponding amounts *Amounts in this section may be different from amounts 14. Miscellaneous Increases to Cash........................... Schedule 1,Line 4 0.00 from Column B of your last reported in Column B. 15.Cash Payments.................................................. Column A,Line a above 15,649.41 report. Some amounts inColumn A may be negative 16. ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ 2,457.59 figures that should be subtracted from previous If this is a termination statement, Line 16 must be zero, period amounts. If this is the first report being filed 17. LOAN GUARANTEES RECEIVED........................... Schedule B,Part 2 $ 0.00 for this calendar year, only carry over the amounts from Lines 2, 7, and 9(if Cash Equivalents and Outstanding Debts any). 18. Cash Equivalents........................................ See instructions on reverse $ 0.00 19. Outstanding Debts......................... Add Line 2+Line 9 in Column B above $ 12,514.19 FPPC Form 460(January/05) FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772) Campaign Disclosure Statement Type or print in ink SUMMARY PAGE Amounts may be rounded Statement covers period Summary Page to whole dollars from O1/01/2010 SEE INSTRUCTIONS ON REVERSE through 06/30/2010 Page 3 of 9 NAME OF FILER ID NUMBER Matthew Harper for City Council 2010 1325962 Column A Column B Calendar Year Summary for Candidates Contributions Received TOTALTHIS PERIOD CALENDARYEAR Running in Both the State Prima and (FROMATTACHED SCHEDULES) TOTALTO DATE g Primary General Elections 1 Monetary Contributions Schedule Linea $ 3 466 00 $ 3 466 00 1/1 through 6/30 7/1 to Date 2 Loans Received Schedule Line 520 00 520 00 00 986 3 986 00 20 Contributions 3 SUBTOTAL CASH CONTRIBUTIONS Add Lines 1+p $ 3 $ Received $ $ 4 Nonmonetary Contributions Schedule C Line 3 129 29 129 29 21 Expenditures 5 TOTAL CONTRIBUTIONS RECEIVED Add Lines 3+4 $ 4 115 29 $ 4 115 29 Made $ $ Expenditures Made Expenditure Limit Summary for State 6 Payments Made Schedule Line $ 250 00 $ 250 00 Candidates 7 Loans Made Schedule H Line 3 0 00 0 00 22 Cumulative Expenditures Made 8 SUBTOTALCASH PAYMENTS Add Lines 6+7 $ 250 00 $ 250 00 (if Subject to Voluntary Expenditure Limit) 9 Accrued Expenses (Unpaid Bills) Schedule F Line 3 152 25 152 25 Date of Election Total to Date 10 Nonmonetary Adjustment Schedule Linea 129 29 129 29 (mm/dd/yy) 11 TOTAL EXPENDITURES MADE Add lines 8+g+10 $ 531 54 $ 531 54 � —/ $ Current Cash Statement —J $ 12 Beginning Cash Balance Previous Summary Page Line 16 $ 0 00 To calculate Column B add 13 Cash Receipts Column A Line 3 above 3 986 00 amounts in Column A to the corresponding amounts Amounts in this section may be different from amounts 14 Miscellaneous Increases to Cash Schedule 1 Line 4 0 00 from Column B of your last reported in Column B report Some amounts in 15 Cash Payments Column A Line 8 above 250 00 Column A may be negative 16 ENDING CASH BALANCE Add Lines 12+13+14 then subtract Line 15 $ 3 736 00 figures that should be subtracted from previous If this is a termination statement Line 16 must be zero period amounts If this is the first report being filed 17 LOAN GUARANTEES RECEIVED schedule B Part 2 $ 0 00 for this calendar year only carry over the amounts Cash Equivalents and Outstanding Debts from Lines 2 7 and 9(if � g any) 18 Cash Equivalents See instructions on reverse $ 0 00 19 Outstanding Debts Add Line 2+Line 9 in Column B above $ 672 25 FPPC Form 460(January/05) FPPC Toll Free Helpline 866/ASK FPPC(866/275 3772) Statement of Organization STATEMENT OF ORGANIZATION Recipient Committee410 FORM INSTRUCTIONS ON REVERSE 3 of 3 COMMITTEE NAME I D NUMBER Matthew Harper for City Council 2010 1325962 4 Type of Committee (Continued) Not formed to support or oppose specific candidates or measures in a single election Check only one box ❑CITY Committee ❑COUNTYCommittee ❑STATECommittee PROVIDE BRIEF DESCRIPTION OF ACTIVITY List additional sponsors on an attachment NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREET ADDRESS NO AND STREET CITY STATE ZIP CODE ❑ �� Check box and provide the date this committee qualified as a small contributor committee If the committee qualified as a small Date qualified contributor committee on January 1 2001 enter 1/1/01 5 Termination Requirements By signing the verification thetreasurer assistant treasurer and/or candidate officeholder or proponent certify that all of the following conditions have been met This committee has ceased to receive contributions and make expenditures This committee does not anticipate receiving contributions or making expenditures in the future This committee has eliminated or has no intention or ability to discharge all debts loans received and other obligations This committee has no surplus funds and This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions There are restrictions on the disposition of surplus campaign funds held by elected officers who are leaving office and by defeated candidates Refer to Government Code Section 89519 - Additional filing obligations will be incurred if after terminating the committee receives or spends any funds or receives the forgiveness of a loan repayments of loans made to others or any other receipts FPPC Form 410(June/09) www neMle com FPPC Toll Free Helpline 866/ASK FPPC Statement of Organization STATEMENT OF ORGANIZATION Recipient Committee CALIFORNIA, 4 . - INSTRUCTIONS ON REVERSE 2 of 3 COMMITTEE NAME I.D.NUMBER Matthew Harper for City Council 2010 4.Type of Committee Complete the applicable sections. e e e e • List the name of each controlling officeholder,candidate,or state measure proponent. If candidate or officeholder controlled,also list the elective office sought or held,and district number, if any, and the year of the election. . List the political party with which each officeholder or candidate is affiliated or check"non-partisan." • If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. OR NAME OF CANDID/TE/OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT AP HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY City Council Member 0 Non-Partisan Matthew Harper Huntington Beach 2010 ❑ Non-Partisan • List the financial institution where the campaign bank account is located(controlled"candidate election"committees only) NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S)NAME OR MEASURE(S)FULL TITLE(INCLUDE BALLOT NO.OR LETTER) CANDIDATE(S)OFFICE SOUGHTOR HELD OR MEASURE(S)JURISDICTION (INCLUDE DISTRICTNO.,CITY OR COUNTY,AS APPLICABLE) CHECK ONE SUPPORT OPPOSE SUPPORT OPPOSE FPPC Form 410(June/09) www.netfi*le.com FPPC Toll-Free Helpline:866/ASK-FPPC Statement of Organization STATEMENT OF ORGANIZATION Recipient Committee LIFORKIA. -4-10 . - INSTRUCTIONS ON REVERSE 3 of 3 COMMITTEE NAME I.D.NUMBER Matthew Harper for City Council 2010 4.Type of Committee (Continued) Not formed to support or oppose specific candidates or measures in a single election. Check only one box: ❑CITY Committee ❑COUNTYCommittee ❑STATECommittee PROVIDE BRIEF DESCRIPTION OF ACTIVITY jj� • List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREET ADDRESS NO.AND STREET CITY STATE ZIP CODE ❑ _�_� Check box and provide the date this committee qualified as a small contributor committee. If the committee qualified as a small Datequalified contributor committee on January 1,2001,enter 1/1/01. 5.Termination Requirements By signing the verification,the treasurer,assistant treasurer and/or candidate,officeholder,or proponent certifythat all of the following conditions have been met: • This committee has ceased to receive contributions and make expenditures; • This committee does not anticipate receiving contributions or making expenditures in the future; • This committee has eliminated or has no intention or ability to discharge all debts, loans received, and other obligations; • This committee has no surplus funds; and • This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions. -- There are restrictions on the disposition of surplus campaign funds held by elected officers who are leaving office and by defeated candidates. Refer to Government Code Section 89519. -- Additional filing obligations will be incurred if, after terminating, the committee receives or spends any funds, or receives the forgiveness of a loan, repayments of loans made to others, or any other receipts. FPPC Form 410(June/09) www.netfile.com FPPC Toll-Free Helpline:866/ASK-FPPC