HomeMy WebLinkAboutPeterson, Erik H. - 2012 FPPC Campaign Disclosure Forms For (2) Recipient Committee Type or print in ink. COVER PAGE-PART2
Campaign Statement ALIF®` . � a ® 1 .
Cover Page— Pant 2
Page 2 of 6
5. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHOLDER OR CANDIDATE NAME OF BALLOT MEASURE
OFFICE SOUGHT OR HELD(INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) BALLOT NO,OR LETTER JURISDICTION ❑ SUPPORT
❑ OPPOSE
RESIDENTIAL/BUSINESS ADDRESS (NO.AND STREET) CITY STATE ZIP
Identify the controlling officeholder, candidate, or state measure proponent, if any.
NAME OF OFFICEHOLDER,CANDIDATE,OR PROPONENT
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 OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
contributions or make expenditures on behalf of your candidacy.
COMMITTEE NAME I.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE? 7. Primarily Formed Candidate/Officeholder Committee List names of
officeholder(s) or candidate(s)for which this committee is primarily formed.
❑ YES ❑ NO
COMMITTEE ADDRESS STREETADDRESS (NO P.O.BOX) NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT
❑ OPPOSE
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
COMMITTEE NAME I.D. NUMBER
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT
❑ OPPOSE
NAME OF TREASURER CONTROLLED COMMITTEE? NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ YES ❑ NO ❑ SUPPORT
❑ OPPOSE
COMMITTEE ADDRESS STREETADDRESS (NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE Attach continuation sheets if necessary
FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
State of California
Campaign Disclosure Statement Type or print in ink. SUMMARYPAGE
Amounts may be rounded Statement covers period
BE=
Summary rage to whole dollars. from 10/21/2012
SEE INSTRUCTIONS ON REVERSE through 12/31/2012 Page 3 of 6
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012 1342226
Column A Column B Calendar Year Summary for Candidates
Contributions Received TOTALTHIS PERIOD CALENDARYEAR Running In Both the State Prima and
(FROM ATTACHED SCHEDULES) TOTALTODATE g
General Elections
1. Monetary Contributions ........................................... Schedule A,Line 3 $ 2,110.00 $ 12,870.00
2. Loans Received ...................................................... Schedule e,Line 3 0.00 5,700.00 111 through 6130 711 to Date
3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1+2 $ 2,110.00 $ 18,570.00 20. Contributions
Received $ $
4. Nonmonetary Contributions.................................... Schedule C,Line 3 0.00 0.00
21. Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED ...............•..••....•.•Add Lines 3+4 $ 2,110.00 $ 18,570.00 Made $ $
Expenditures Made Expenditure Limit Summary for State
6. Payments Made....................................................... Schedule E,Line 4 $ 3,200.00 $ 9,674.95 Candidates
7. Loans Made............................................................. Schedule H,Line 3 0.00 0.00
22. Cumulative Expenditures Made*
8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6+7 $ 3,200.00 $ 9,674.95 (If Subject to Voluntary Expenditure Limit)
9. Accrued Expenses (Unpaid Bills) ...............................Schedule F Line 3 0.00 0.00
Date of Election Total to Date
10. Nonmonetary Adjustment ..........................................Schedule C,Line 3 0.00 0.00 (mm/dd/yy)
11. TOTAL EXPEN DITURES MADE................................Add Lines 8+9+10 $ 3,200.00 $ 9,674.95 J $
Current Cash Statement J $
12. Beginning Cash Balance....................... Previous summary Page,Line 16 $ 10,344.47
To calculate Column B,add
13. Cash Receipts ................................................... Column A,Line 3 above 2,110.00 amounts in Column A to the
corresponding amounts *Amounts in this section may be different from amounts
o.00
14.Miscellaneous Increases to Cash........................... Schedule 1,Line 4 from Column B of your last reported in Column B.
15. Cash Payments........... """""""""".... ......... Column A,Line 8above 3,200.00 report. Some amounts in
Column A may be negative
16. ENDING CASH BALANCE.......... Add Lines 12+ 13+ 14,then subtract Line 15 $ 9,254.47 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 e,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
any).
18, Cash Equivalents........................................ See instructions on reverse $ 0.00
19. Outstanding Debts......................... Add Line 2+Line 9 in Column a above $ 5,700.00 FPPC Form 460(Januaryl05)
FPPC Toll-Free Helpline: 866IASK-FPPC(866/275-3772)
Recipient Committee T COVER PAGE
ype or print in ink. Date Stamp W- 11
Campaign Statement
Cover Page E-filed on:
(Government Code Sections 84200-84216.5)
Statement covers period Date of election if aI l�le, v l^ !
(Month, Day, Year) f l"i 12: 1 7
from 10/01/2012 For Official Use Only
t
SEE INSTRUCTIONS ON REVERSE through 10/20/2012 a
1. Type of Recipient Committee: All Committees-Complete Parrs 1,2,3,and 4. 2. Type of Statement:
RI Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure iX Preelection Statement ❑ Quarterly Statement
Q State Candidate Election Committee Committee ❑ Semi-annual Statement ❑ Special Odd-Year Report
Q Recall Q Controlled Termination
plete Part5) Sponsored ❑ ❑ Supplemental Preelection
P (Also file a Form 410 Termination) Statement-Attach Form 495
(Also Complete Part 6)
❑ General Purpose Committee ❑ Amendment(Explain below)
Q Sponsored ❑ Primarily Formed Candidate/
Q Small Contributor Committee Officeholder Committee
Q Political Party/Central Committee (Also Complete Part7)
3. Committee Information I.D. NUMBER 1342226 Treasurer(s)
COMMITTEE NAME (OR CANDIDA NAME OF TREASURER
Erik Peterson for City Council 2012
Erik Peterson
MAILING ADDRESS
5122 Bolsa Avenue Ste. 107
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
5122 Bolsa Avenue Ste. 107 Huntington Beach CA 92649 (714) 580-6980
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
Huntington Beach CA 92649 (714) 580-6980
MAILING ADDRESS (IF DIFFERENT) NO.AND STREET OR P.O. BOX MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX/E-MAIL ADDRESS OPTIONAL: FAX/E-MAIL ADDRESS r
erikpetersonhb@qmail.com
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 and correct.
Executed on L`� Z2� 11� By
/^� a or Assistant Treasurer
Executed on J / (2— B
Date Sl-gnatomlbof Controlling Officeholder,Candidate,State Measure Proponent or Responsible Officer of Sponsor
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(8661275-3772)
State of California
Type or print in ink. COVERPAGE-PART2
Recipient Committee !__2�__
Campaign StatementCover Page— Part 2PageF__27___
5. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHOLDER OR CANDIDATE NAME OF BALLOT MEASURE
Erik Peterson
NCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) BALLOT NO.OR LETTER JURISDICTION ❑ SUPPORT
❑ OPPOSE
City Council Member
RESIDENTIAUBUSINESS ADDRESS (NO.AND STREET) CITY STATE ZIP
5122 Bolsa Avenue Ste. 107 Identify the controlling officeholder, candidate, or state measure proponent, if any.
Huntington Beach CA 92649
NAME OF OFFICEHOLDER,CANDIDATE,OR PROPONENT
Related Committees Not Included in this Statement: Listany committees
not included in this statement that are controlled by you or are primarily formed to receive OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
contributions or make expenditures on behalf of your candidacy.
COMMITTEENAME I.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE? 7. Primarily Formed Candidate/Officeholder Committee List names of
officeholder(s)or candidate(s)for which this committee is primarily formed.
❑ YES ❑ NO
COMMITTEE ADDRESS STREET ADDRESS (NO P.O.BOX) NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
COMMITTEE NAME I.D. NUMBER
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT
❑ OPPOSE
NAME OF TREASURER CONTROLLED COMMITTEE? NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ YES ❑ NO ❑ SUPPORT
❑ OPPOSE
COMMITTEE ADDRESS STREET ADDRESS (NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE Attach continuation sheets if necessary
FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
State of California
Campaign Disclosure Statement Type or print in ink. SUMMARY PAGE
Amounts may be rounded Statement covers period Em
Summary Page to whole dollars.
from 10/01/2012
SEE INSTRUCTIONS ON REVERSE through 10/20/2012 Page 3 of 7
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012
1342226
Column A Column B Calendar Year Summary for Candidates
Contributions Received TOTALTHISPERIOD CALENDARYEAR
(FROM ATTACHED SCHEDULES) TOTALTO DATE Running in Both the State Primary and
General Elections
1. Monetary Contributions ........................................... Schedule A,Line 3 $ $1,440.00 $ $10,760.00
1/1 through 6/30 7/1 to Date
2. Loans Received ...................................................... Schedule B,Line 3 $0.00 $5,700.00
Cont
3. SUBTOTALCASH CONTRIBUTIONS ......................... Add Lines 1+2 $ $1,440.00 $ $16,460.00 20. Receibutions
Received $ $
4. Nonmonetary Contributions.................................... Schedule C,Line 3 $0.00 $0.00
21. Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED ...........................Add Lines 3+4 $ $1,440.00 $ $16,460.00 Made $ $
Expenditures Made Expenditure Limit Summary for State
6. Payments Made....................................................... Schedule E,Line 4 $ $2,277.43 $ $6,474.95 Candidates
7. Loans Made............................................................. Schedule H,Line 3 $0.00 $0.00
22. Cumulative Expenditures Made*
8. SUBTOTALCASH PAYMENTS .................................... Add Lines 6+7 $ $2,277.43 $ $6,474.95 (If Subject to Voluntary Expenditure Limit)
9. Accrued Expenses (Unpaid Bills) ...............................ScheduleF,Line 3 $0.00 $0.00 Date of Election Total to Date
10. Nonmonetary Adjustment ..........................................Schedule C,Line 3 $0.00 $0.00 (mm/dd/yy)
11. TOTAL EXPEN DITURES MADE................................Add Lines 8+9+10 $ $2,277.43 $ $6,474.95 $
Current Cash Statement $
12. Beginning Cash Balance....................... Previous summary Page,Line 16 $ $11,181.90
To calculate Column B,add
13. Cash Receipts ................................................... Column A,Line 3above $1,440.00 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.
2,277.43 report. Some amounts in
15. Cash Payments.................................................. Column A,line s above $ Column A may be negative
16. ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ $10,344.47 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 arny)Lines 2, 7, and 9 (if
$o.00
18. Cash Equivalents........................................ See instructions on reverse $
19. Outstanding Debts......................... Add Line 2+Line 9 in Column B above $ $5,700.00 FPPC Form 460(Januaryl05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
Schedule A Type or print in ink. SCHEDULE A
Monetary Contributions Received Amounts may be rounded Statement covers period ® .
to whole dollars. 1
from 10/01/2012 e
a
SEE INSTRUCTIONS ON REVERSE through 10/20/2012 Page 4 of 7
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012
1342226
DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
RECEIVED (EET A IT RE S SAND ZIP
I.D.NUMBER) CODE * OCCUPATION AND EMPLOYER RECEIVED TH TO DATE
(IF SELF-EMPLOYED,ENTER NAME PERIOD (JAN. 1 -DEC.31) (IF REQUIRED)
OF BUSINESS)
10/01/2012 Justine QIND Homemaker $200.00 $200.00 G12 $200.00
18866 Rockinghorse Lane ❑COM Homemaker
❑OTH
Huntington Beach CA 9
❑SCC
10/03/2012 Jamal Abdelmuti ®IND Executive $100.00 $100.00 G12 $100.00
6567 Even M❑OTH Jacks Surfboards
Huntington Beach CA 92648 [:]PTY
❑SCC
10/05/2012 Warmington Residential California, In $250.00 $250.00 G12 $250.00
❑COM
3090 Pullman Street Q OTH
Huntington Beach CA 92626 ❑PTY
❑SCC
10/05/2012 Carol Woodworth X❑IND Retired $100.00 $100.00 G12 $100.00
20441 Mansard Lane ❑COM Retired
❑OTH
Huntington Beach CA 92646 ❑PTY
[]SCC
10/11/2012 Eugene Haberl BIND Retired $100.00 $100.00 G12 $100.00
6231 Surflanding Lane ❑COM❑OTH Retired
Huntington Beach CA 92648 ❑PTY
❑SCC
SUBTOTAL$ $7so.00
Schedule A Summary 'Contributor Codes
1. Amount received this period—itemized monetary contributions. IND—Individual
(Include all Schedule A subtotals.) $ $1,200.00 COM—RecipientCommittee
(other than PTY or SCC)
2. Amount received this period—unitemized monetary contributions of less than$100 ............................. $ $240.00 OTH—Other(e.g., business entity)
PTY—Political Party
3. Total monetary contributions received this period. SCC—Small contributor committee
Add Lines 1 and 2. Enter here and on the SummaryPa Col A, Line 1. TOTAL $ $1,440.o0
( Page, Column ) FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772)
Schedule A (Continuation Sheet) Type or print in ink. SCHEDULE (CONT.)
Monetary Contributions Received Amounts may be rounded Statement covers period ®FF
to whole dollars. from 10/01/2012through 10/20/2012 Page 5
NAME OF FILER I.D.NUMBER
Erik Peterson for City Council 2012 1342226
DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
RECEIVED (IFCOMMIE,ALSND I.D.NUMB CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE
(IF SELF-EMPLOYED,ENTER NAME PERIOD F REQUIRED)
OF BUSINESS)
10/16/2012 Greer Bros. Storage ❑IND $250.00 $250.00 G12 $2
❑COM
18831 Gothard Street X❑OTH
Huntington Beach CA 92648 ❑PTY
❑SCC
10/18/2012 Ron Higby ®IND Retired $200.00 $200.00 G12 $200.00
❑COM
8932 Modesto Cir. #1211B ❑OTH Retired
Huntington Beach CA 92646 [:]PTY
[]SCC
❑IND
[:]COM
❑OTH
❑PTY
❑SCC
❑IND
[:]COM
❑OTH
❑PTY
[:]SCC
❑IND
❑COM
❑OTH
❑PTY
❑SCC
SUBTOTAL$ $450.00f' '`
*Contributor Codes
IND—Individual
COM—Recipient Committee
(other than PTY or SCC)
OTH—Other(e.g., business entity)
PTY—Political Party FPPC Form 460(January/05)
SCC—Small Contributor Committee FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
Type or print in ink. SCHEDULE B-PART 1
Schedule B—Part 1 Amounts may be rounded Statement covers period
Loans Deceived to whole dollars.
from 10/01/2012 Fg,
SEE INSTRUCTIONS ON REVERSE through 10/20/2012 6 of 7
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012
1342226
IF AN INDIVIDUAL, ENTER a (b) (c) (d) (e) (f g)
FULL NAME,STREET ADDRESS AND ZIP CODE OUTSTANDING AMOUNT OUTSTANDING INTEREST ORIGINAL CUMULATIVE
OCCUPATION AND EMPLOYER BALANCE AMOUNT PAID BALANCEAT
OF LENDER (IF SELF-EMPLOYED,ENTER BEGINNING THIS PERIOD RECEIVED THIS OR FORGIVEN CLOSE OF THIS PAID THIS AMOUNT OF CONTRIB
R I.D.NUMBER) NAMEOF BUSINESS) PERIOD THIS PERIOD* PERIOD PERIOD LOAN TO DATE
Erik Peterson
❑PAID CALENDARYEAR
$700.00 0.00 $700.00 $5,700.00
$
a Avenue ❑FORGIVEN RATE PER ELECTION**
suite 107 G10 $80.00
Huntington Beach CA 92649 $ S700.00 $ $0.00 $ $ 08/29/2012 $c1z S5,700.00
t® IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED
Erik Peterson ❑PAID CALENDARYEAR
$5,000.00 0.00 $5,000.00 $5,700.00
5122 Bolsa Avenue ❑FORGIVEN RATE PER ELECTION**
suite 107 G10 $80.00
Huntington Beach CA 92649 $ $5,000.00 $ $0.00 $ $ 09/28/2012 $G12 $5,700.00
t® IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED
❑PAID CALENDARYEAR
❑FORGIVEN RATE PER ELECTION**
t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED
SUBTOTALS $ $o.00$ $0.00$ $5,700.00$ So.00
(Enter(e)on
Schedule B Summary Schedule E,Line 3)
1. Loans received this period................................... ............... $ $0.00
(Total Column(b)plus unitemized loans of less than$100.) tContributor Codes
$0.00 IND—Individual
2. Loans paid or forgiven this period .........................................................................................................$ COM—RecipientCommittee
(Total Column(c)plus loans under$100 paid or forgiven.) (other than PTY or SCC)
(Include loans paid by a third party that are also itemized on Schedule A.) OTH—Other(e.g., business entity)
PTY—Political Party
3. Net change this period. Subtract Line 2 from Line 1. $0.00 SCC—Small Contributor Committee
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. FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
SCHEDULEE
Type or print in ink.
Schedule Statement covers period
Amounts may be rounded ®. , •
Payments Made to whole dollars. ®"
from 10J01J2012 4
SEE INSTRUCTIONS ON REVERSE through 10/20/2012 Page 7 of 7
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012 1342226
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 defens ices (legal, accounting) VOT
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
California Latino voter Guid LIT $700.00
930 Colorado Blvd. building 2
Los Angeles CA 90041
PennySaver LIT $1,524.30
1300 Specialty Drive
Vista CA 92081
* Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ $2,224.30
Schedule E Summary
1. Itemized payments made this period. Include all Schedule E subtotals. ........................ $ $2,224.30
2. Unitemized payments made this period of under$100 .......................................................................................................................................... $ $53.13
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 $ $2,277.43
FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
Recipient Committee COVER PAGE
Campaign Statement Type or print in ink. Date StampMR
Cover Page E-filed on:
(Government Code Sections 84200-84216.5)
Statement covers period Date of election If appp@$61f'ti _�' _ page 1 of 9
07/01/2012 (Month, Day, Year)
from For Official Use Only
SEE INSTRUCTIONS ON REVERSE through 09/30/2012
1. Type of Recipient Committee: All Committees-Complete Parts 1,2,3,and 4. 2. Type of Statement:
0 Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure 0 Preelection Statement ❑ Quarterly Statement
p State Candidate Election Committee Committee ❑ Semi-annual Statement ❑ Special Odd-Year Report
Q Recall Q Controlled
(AlsoComplefePart5) Sponsored ❑ Termination Statem reelection
p (Also file a Form 410 Termination) Statement-Attach Form 495
❑ General Purpose Committee (Also Complete Parts) ❑ (Explain )
Amendment Ex lain below
p Sponsored ❑ Primarily Formed Candidate/
p Small Contributor Committee Officeholder Committee
p Political Party/Central Committee (Also Complete Part7)
3. Committee Information I.D. NUMBER Treasurer(s)
1342226
COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER
Erik Peterson for City Council 2012
MAILING ADDRESS
5122 Bolas. Avenue Ste. 107
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
5122 Bolsa Avenue Ste. 107 Huntington Beach CA 92649 (714) 580-6980
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
Huntington Beach CA 92649 (714) 580-6980
MAILING ADDRESS (IF DIFFERENT) NO.AND STREET OR P.O. BOX MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX/E-MAIL ADDRESS OPTIONAL: FAX I E-MAIL ADDRESS
erikpetersonhb@gmail.com
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 and correct.
Executed on t /J A By
Date Signature of Treasurer or AssistantTreasurer�
Executed on �) :��Z By —
iDate SignaturdofControlling.Officeholder,Candidate,State Measure Proponent or Responsible Officer of Sponsor
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(866/276-3772)
State of California
Type or print in ink. COVER PAGE-PART 2
Recipient Committee ORNIA
Campaign Statement ®� s
Cover Page--Part 2
Page 2 of 9
5. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHOLDER OR CA LLOT MEASURE
Erik Peterson
OFFICE SOUGHT OR HELD(INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) BALLOT NO.OR LETTER JURISDICTION ❑ SUPPORT
❑ OPPOSE
City Council Member
RESIDENTIAUBUSINESS ADDRESS (NO.AND STREET) CITY STATE ZIP
5122 Bolsa Avenue Ste. 107 Identify the controlling officeholder, candidate, or state measure proponent, if any.
Huntington Beach CA 92649
NAME OF OFFICEHOLDER,CANDIDATE,OR PROPONENT
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 OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
contributions or make expenditures on behalf of your candidacy.
COMMITTEE NAME I.Q. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE? 7• Primarily Formed Candidate/Officeholder Committee List names of
officeholders)or candidate(s) for which this committee is primarily formed.
❑ YES ❑ NO
COMMITTEE ADDRESS STREETADDRESS (NO P.O.BOX) NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
COMMITTEE NAME I.D. NUMBER
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT
❑ OPPOSE
NAME OF TREASURER CONTROLLED COMMITTEE? NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ YES ❑ NO ❑ SUPPORT
❑ OPPOSE
COMMITTEE ADDRESS STREETADDRESS (NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE Attach continuation sheets if necessary
FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/276-3772)
State of California
Campaign Disclosure Statement Type or print in ink. SUMMARY PAGE
Amounts may be rounded Statement covers period � ® -
Summary Page to whole dollars. A � ® 1
from 07/01/2012 ® -
SEE INSTRUCTIONS ON REVERSE
through 09/30/2012 Page 3 of 9
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012 1342226
Contributions Received TO Column Column B Calendar Year Summary for Candidates
TALTHISPERIOD CALENDARYEAR Running in Both the State Primary and
(FROM ATTACHED SCHEDULES) TOTALTO DATE Primary
General Elections
00 080.
1. Monetary Contributions ........................................... Schedule A,Line 3 $ $6, $ $9,070.00 1/1 through 6/30 7/1 to Date
2. Loans Received ...................................................... Schedule B,Line 3 $5,700.00 $5,700.00
3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines l+2 $ $11,780.00 $ $14,770.00 20. Contributions
Received $ $
4. Nonmonetary Contributions.................................._ schedule C,Line 3 $0.00 $0.00 21. Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED ...........................Add Lines 3+4 $ $11,780.00 $ $14,770.00 Made $ $
Expenditures Made Expenditure Limit Summary for State
6. Payments Made....................................................... schedule E Line 4 $ $4,197.52 $ $4,197.52 Candidates
7. Loans Made............................................................. Schedule H,Line 3 $0.00 $0.00
22. Cumulative Expenditures Made*
8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6+7 $ $4,197.52 $ $4,197.52 (If Subject to Voluntary Expenditure Limit)
9. Accrued Expenses (Unpaid Bills) ...............................Schedule F Line 3 $0.00 $0.00 Date of Election Total to Date
10. Nonmonetary Adjustment ..........................................Schedule C,Line 3 $0.00 $0.00 (mm/dd/yy)
11. TOTAL EXPENDITURES MADE................................Add Lines 8+9+10 $ $4,197.52 $ $4,197.52
Current Cash Statement $
12. Beginning Cash Balance....................... Previous summary Page,Line 16 $ $3,349.42 To calculate Column B,add
13.Cash Receipts ................................................... Column A,Line 3 above $11,780.00 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 8 above $4,197.52 report. Some amounts in
Column A may be negative
16. ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ $10,931.90 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 arny)Lines 2, 7, and 9(if
18. Cash Equivalents.........., $o.00
............................. See instructions on reverse $
19. Outstanding Debts......................... Add Line 2+Line 9 in Column B above $ $5,700.00 FPPC Form 460(January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC(866/275-3772)
Schedule A Type or print in ink. SCHEDULE A
Amounts may be rounded Statement covers period
Monetary Contributions Received to whole dollars. ® ' ® � �
from 07/01/2012 ® "
SEE INSTRUCTIONS ON REVERSE through 09/30/2012 Page 4 of 9
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012 1342226
STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
DATE FULL NAME,
RECEIVED ( ACOMMITTEE,ALSENTERI,D.NUMBER) CODE * OCCUPATION AND EMPLOYER RECEIVED TH TO DATE
(IFSELF-EMPLOYED,ENTER NAME PERIOD (JAN. 1 -DEC.31) (IF REQUIRED)
OF BUSINESS)
urf & Sport, LLC MIND $520.00 $520.00 G10 $500.00
❑COM G12 $520.00
16350 Gothard suite 101 ❑% OTH
Hunting ❑PTY
[]SCC
07/16/2012 Bob Jones ®IND Owner $520.00 $520.00 G12 $520.00
❑COM Perfo
7071 warner Ave. #F92 [I OTH
❑PTY
Solutions
Huntington Beach CA 92647 ❑SCC
07/16/2012 U $520.00 $520.00 G10 $520.00
❑COM G12 $520.00
16702 Producer Lane ®OTH
Huntington Beach CA 92649 ❑PTY
❑SCC
07/17/2012 John Freeman MIND Retired $100.00 $100.00 G10 $100.00
❑COM G12 $100.00
17852 Romelle Ave OTH Retired
Santa Ana CA 92705 ❑PTY
❑SCC
07/18/2012 Susan Jervik ®IND Nurse $100.00 $100.00 G10 $250.00
❑COM G12 $100.00
15391 Cambay Lanet ❑OTH Whittier Hospital
Huntington Beach CA 92649 ❑PTY
[]SCC
SUBTOTAL$ $1,760.00
Schedule A Summary Contributor Codes
1. Amount received this period-itemized monetary contributions. IND-Individual
(Include all Schedule A Subtotals.).............. $5,850.00 COM—RecipientCommittee
$ (other than PTY or SCC)
2. Amount received this period-unitemized monetary contributions of less than$100 ............................. $ $230.00 OTH—Other(e.g., business entity)
p ry PTY—Political Party
3. Total monetary contributions received this period. SCC-Small contributor committee
Add Lines 1 and 2. Enter here and on the SummaryCol A, Line 1. TOTAL $ $6,080.00
( Page, Column )���������������� FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772)
Schedule A (Continuation Sheet) Type or print in ink. SCHEDULEA (CONT.)
Monetary Contributions Received Amounts may be rounded Statement covers period
to whole dollars. ® � ® ® O
from 07/O1/2o12VQRM
through 09/30/2012 Page 5 of 9
NAME OF FILER I.D.NUMBER
Erik Peterson for City Council 2012 1342226
DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
RECEIVED (IF COMMITTEE,ALSO ENTER I.D.NUMBER) CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DAT
IF SELF-EMPLOYED,ENTER NAME PERIOD (JAN. 1 -DEC.31) (IF REQUIRED)
OF BUSINESS)
07/19/2012 Greg Resnokoff ®IND Owner $500.00 $500.00 G1 00
3842 Seascape Drive ❑COM❑OTH Beach Wire & Cable
Huntington Beach CA 92649 [-]PTY
❑SCC
07/24/2012 C ect Congressman Dana ❑IND $500.00 $500.00 G12 $500.00
Rohrabacher ❑COM
PO Box 823 ®OTH
Huntington Be Y
❑SCC
07/30/2012 Dorothy Seldy ®IND Retired $400.00 $400.00 G10 $520.00
❑COM G
17881 Felson Cir ❑OTH Retired
Huntington Beach CA 92649 ❑PTY
❑SCC
07/31/2012 Richard Moore ❑RIND Program Manager $520.00 $520.00 G12 $520.00
6921 Canterbury Dive ❑COM Molina Health Care
❑OTH
Huntington Beach CA 92647 ❑PTY
❑SCC
07/31/2012 SMI Technologies MIND $500.00 $500.00 G12 $500.00
❑COM
2510 Warren Ave ®OTH
Cheyenne WY 82001 ❑PTY
❑SCC
SUBTOTAL$ $2,420.00
*Contributor Codes
IND-Individual
COM-Recipient Committee
(other than PTY or SCC)
OTH-Other(e.g., business entity)
PTY-Political Party FPPC Form 460(January/05)
SCC-Small Contributor Committee FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772)
Schedule A (Continuation Sheet) Type or print in ink. SCHEDULE (CONT.)
Monetary Contributions Received Amounts may be rounded Statement covers period
to whole dollars. F
from 07/01/2012
through 09/30/2012 of 9
NAME OF FILER I.D.NUMBER
Erik Peterson for City Council 2012 1342226
DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
RECEIVED (IF COMMITTEE,ALSENTERI.D.NUMBER) CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE
(IF SE PERIOD (JAN. 1 -DEC.31) (IF REQUIRED)
OF BUSINESS)
08/23/2012 Stuart Souders ®IND Physician $100.00 $100.00 G12
51 Via Corona Drive ❑COM Self❑OTH
Huntington Beach CA 92647 []PTY
❑SCC
09/01/2012 Christine King $100.00 $100.00 G10 $100.00
❑COM G12 $100.00
5212 Franklin Circle ❑OTH Homemaker
❑PTY
❑SCC
09/03/2012 Cynthia Droeger ®IND Consultant $150.00 $150.00 G12 $150.00
❑6752 ❑OTH COM Self
Huntington Beach CA 92647 [:]PTY
❑SCC
09/08/2012 Donald Garrick ❑x1ND Retired $100.00 $100.00 G12 $100.00
6952 Los Amigos Circle ❑COM Retired
❑OTH
Huntington Beach CA 92647 ❑PTY
[]SCC
09/08/2012 Catherine Green ®IND Director $100.00 $100.00 G12 $100.00
6151 Kimberly Drive ❑COM OCWD❑OTH
Huntington Beach CA 92647 ❑PTY
❑SCC
SUBTOTAL$ $550.0041
"Contributor Codes
IND—Individual
COM—Recipient Committee
(other than PTY or SCC)
OTH—Other(e.g., business entity)
PTY—Political Party FPPC Form 460(January/05)
SCC—Small Contributor Committee FPPC Toll-Free Helpline:866/ASK-FPPC(866/276-3772)
Schedule A (Continuation Sheet) Type or print in ink. SCHEDULE (CONT.)
Monetary Contributions Received Amounts may be rounded Statement covers period
A
to whole dollars.
from 07/01/2012
through 09/30/2012 page 7 of 9
NAME OF FILER I.D.NUMBER
Erik Peterson for City Council 2012 1342226
DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
RECEIVED (IFCOMMITTEE,ALSENTERI.D.NUMBER) CODE * OCCUPATION AND EMPLOYER CALENDAR YEAR TO DATE
(IF SELF-EMPLOYED,ENTER NAME PERIOD (JAN. 1 -DEC.31) (IF REQUIRED)
OF
14/2012 American Precision Hydraulics ❑IND $520.00 $520.00 G12 $520.00
❑COM
5601 Research Drive ®OTH
Hun [-]PTY
❑SCC
09/14/2012 Phillip Burtis RIND Engineer $150.00 $150.00 G12 $150.00
1 ne ❑COM❑OTH EgeCat, Inc
Huntington Beach CA 92647 ❑PTY
❑SCC
09/28/2012 Elizabeth Johansson RIND Retired $250.00 $250.00 G12 $250.00
6882 Via Corona Drive ❑COM❑OTH Retired
Huntington Beach CA 92647 []PTY
❑SCC
09/30/2012 Charles Falzon RIND Manager $200.00 $200.00 G12 $200.00
6422 Mukai Ct. Computer Sciences
❑OTH
Corporation
Huntington Beach CA 92647
❑PTY
❑SCC
❑IND
❑COM
❑OTH
❑PTY
[]SCC
SUBTOTAL$ $1,120.00
"Contributor Codes
IND-Individual
COM-Recipient Committee
(other than PTY or SCC)
OTH-Other(e.g., business entity)
PTY-Political Party FPPC Form 460(January/05)
SCC-Small Contributor Committee FPPC Toll-Free Helpline:866/ASK-FPPC(866/276-3772)
Schedule B—Part Type or print in ink. Statement covers_period
SCHEDULER-PART1
Amounts may be rounded p
Loans Received to whole dollars. A ®k A 14 •
from 07/01/2012 fQRM
SEE INSTRUCTIONS ON REVERSE through 09/30/2012 page 8 of 9
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012 1342226
IF AN INDIVIDUAL, ENTER a (b) (0 ( ► (e) (g
FULL NAME,STREET ADDRESS AND ZIP CODE OUTSTANDING AMOUNT OUTSTANDING INTEREST ORIGINAL CUMULATIVE
BALANCE
OF LENDER OCCUPATION AND EMPLOYER AMOUNT PAID
RECEIVED THIS BALANCEAT PAID THIS AMOUNT OF CON
YED,ENTER BEGINNING THIS PERIOD OR FORGIVEN* CLOSE OF THIS PERIOD LOAN TO DATE
NAMEOFBUSINESS) THIS PERIOD
Erik Peterson
❑PAID CALENDAR YEAR
$ $ $700.00 0
$ $
5122 Bolas Avenue RATE❑FORGIVEN PER ELECTION**
suite 107 G10 $80.00
Huntington Beach CA 92649 $ $0.00 $ $700.00 $ $ 08/29/2012 $G12 $5,700.00
tpq IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED
Erik Peterson
❑PAID CALENDARYEAR
$ $ $5,000.00 0.00 $ $ $5,000.00 $ $5,700.00
5122 Bolsa Avenue ❑FORGIVEN RATE PER ELECTION**
suite 107 G10 $80.00
Huntington Beach CA 92649 $ $0.00 $ $5,000.00 $ $ 09/28/2012 $G12 $5,700.00
t® IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED
❑PAID CALENDARYEAR
❑FORGIVEN RATE PERELECTION*"
t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED
SUBTOTALS $ $5,700.00$ $0.00$ $5,700.00$ $0.00
Schedule B Summary (Enter ,Lin
Schedule E,Line 3)
1. Loans received this period.................................................................................................................... $ $5,700.00
(Total Column(b)plus unitemized loans of less than$100.) tContributor Codes
IND—Individual
2. Loans paid or forgiven this period ......................................................................................................... $ $0.00 COM—RecipientCommittee
(Total Column(c)plus loans under$100 paid or forgiven.) (other than PTY or SCC)
(Include loans paid by a third party that are also itemized on Schedule A.) OTH—Other(e.g., business entity)
PTY—Political Party
3. Net change this period. Subtract Line 2 from Line 1. $5,700.00 SCC—Small Contributor Committee
9 p ( )............................................................... NET $
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. FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)
SCHEDULEE
Type or print in ink.
Schedule E Amounts may be rounded Statement covers period ® .
Payments Made to whole dollars.
from 07/01/2012
SEE INSTRUCTIONS ON REVERSE through 09/30/2012 Page 9 of 9
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012 1342226
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 PEr 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 rint ads WEB information technology costs (interne
NAME AND ADDRESS OF PAYEE
(IF COMMITTEE,ALSO ENTER I.D OF PAYMENT AMOUNT PAID
COGS South CMP Signs $1,966.44
3309 S. Main St.
Santa Ana CA
Lady Printing, Inc. [LIT Door Hangers
P.O. Box 8429
Seminole, FL 33775
CRA Voter Guide, ID 1271601 LIT $1,600.00
11230 Gold Express Drive
suite 310-325
Gold River CA 95670
* Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ $4,106.49
Schedule E Summary
1. Itemized payments made this period. Include all Schedule E subtotals. ........................................................................... $ $4,106.49
2. Unitemized payments made this period of under$100 .......................................................................................................................................... $ $91.03
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 $ $4,197.52
FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772)
S
Statement of Organization Type or print in ink Date stal 7__ IA NTEMEN 1-OF ORGANIZA.T ION
Recipient Committee 0,
Statement Type 0 Initial Amendment Te-rmination See Part 5 For Offi(,ial Use Ortiv
Nlotyet qualifiv,,d or List I.D,IlUrnber, List LDS_nurnber: 2012 AUG, -8 id 9: W)
6 16 12 U
Date qualified as committee Date qualified as committee Date of Termination
1. Committee Information 2. Treasurer and Other Principal Officers
iw—
NAME OF COMMITTEE NAME OF TREASURER
Erik Peterson for Huntington Beach City Council 2012 Erik Peterson
STREET ADDRESS(No PO,BOX)
5122 Bolsa Ave. suite 107
FT-REFTADD CITY STATE ZIP DE AREAcor)FT—Ho RE
5122 Bolsa Ave. suite 107 Huntington Beach CA 92649 714-900-3745
F,_TT STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY
Huntington Beach 4-900-3745
MAILING ADDRESS(IF DIFFERENT) STREET ADDRESS(No P.O.BOX)
CITY STATE ZIP CODE AREACODEIPHONE
OPTIONAL: FAX/E-MAILADDRESS
erikpotersonhb@gmaii.com NAME OF PRINCIPAL OFFICER(S)
COUNTY OF DOMICILE COUNTY WHERECOMMITTEE IS ACTIVE IFFERENT Bob Jones
THAN COUNI Y OF DOMICILE STREETADDRESS(No PO.BOX)
Orange 7918 Nomad Circle
CITY STATE CODE AREA CODE/PHONE
Attach additional information on appropriately labeled continuation sheets. Huntington Beach CA 92548 714-249-2658
3. Verification
I have used all reasonable diligence in preparing this staternent and to the best of my knowledge the information contained herein is true and completer I certify under penalty of
perjury under the laws of the State of California that the foregoing is true and correct.
7,
Executed on By go�
SIGN, ASSISTAW I REASURf,R
Executed on '-2--- By
Executed on DArE By f ROLLIN C*FIC LDER,CANIDIDAT rE.ORc-,rATF. PROPONENT
DA - _1101 Dot,GANDIr.)ATE,ORS'PUl".
Executed on By
DATES S*1G,NATU I I F CONTROU 1 NG 0 FFC0 I F.R,CAN D Dfff,,:,OR S'r#Ff,:NIUASU RE I",RCP0,L"N T
FPPC Form 410 (April/2011)
FPPC Toll-Free Helpline: 866/ASK.FPPC (866/276-31172)
Statement Organization
STATEMENT Cyr'CtFcGAI�a AT( N
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME I.0 D.NUMBER
E7�IG �c� y �DZH�X�7,tc�TC�X( ff t Qi1'ccc*,aL_ 20rz— 13JL22Z
4.'hype of Commiffee Complete the applicable sections.
* 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."
o If this committee acts jointly with another c':ontrolk d committee, list the name and identification mlh)hK of the rather controlled committee.
ELECTIVE OFFICE SOUGHT OR FIELD
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROI'ONENT (INCLUDE DIa T RICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
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 RANI{ACCOUNTNUMBER
Wells Fargo 714-625-4280 9572304229
ADDRESS CITY STATE ZIP CODE
5355 Warner Ave. suite 101 Huntington Beach CA 92649
A e Primarily formed to.support or oppose specific candidates or rneasures in a single election. List below:
CANDIDATE(S)NAME OR MEASURE(S)FULL TITLE(INCLUDE BALLOT NO.OR LETTER) CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION
(INCLUDE..DISTRICT NO.,CITY OR COUNTY,AS APPLICABLE) c;HEC.K ON
� E7UrYr>l:� sE
ErikPeterson for Huntington Beach City Council 2012 City Council Member
;t.11'.7r>GfiT UfaE'0SE
FPPC Form 410 (April/2011)
FPPC Toll-Free Helpiine: 666/ASK-FPPC (8661276-3772)
Statement of Organization STATEMENT OP GRGANIZ 1HON
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE CJAME LD.NUMBER
4.Type of Committee (Continued)
a R Not forrned to support or oppose specific;candidates or measurs:S in a single election. Check only one box.
CITY Committee 0 COUNTY Committee [I STATE Committee
PROVIDE BRiEF DES/;RIPTION OF ACTIVITY f
list additional sponsors on are aftsachment.
NAME OF SPC?NSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO,AND STREET CITY STATE ZIP CODE
® e [l .J... �t ..
Date qualified
5.Termination Requirements By signing the verification,the treasurer,assistant treasurer and/or candidate,officeholder,or proponent certify that all of the following conditions have been rnet:
'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 Deform 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.
-- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes Linder Government Code Sections 89511 -
89 18, and are subject to Elections Code Section 18680 and FPPC Regulation 18521�5,
FPPC Farm 410 (April/2011)
FPPC Toll-Free Helpline. 666/ASK-FPPC (8 6/276-377"2)
(�:�OVER PAGE
Recipient Committee Type or print in ink. Date Stamp
Campaign Statement
Cover Page E-filed on:
(Government Code Sections 84200-84216.5) Statement covers period Date of election if applicaMeN JUL 3 1 13: 4 1 IPage I of '7
(Month, Day, Year)
from 01/01/2012 For f.1.1 U,
For Official Urea Onir
-ZT--U-1-4
SEE INSTRUCTIONS ON REVERSE through 4
1. Type of Recipient Committee: All Committees-Complete Parts 1,2,3,and 4. 2. Type of Statement:
Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure rl Preelection Statement rl Quarterly Statement
0 State Candidate Election Committee Committee Semi-annual Statement [] Special Odd-Year Report
0 Recall 0 Controlled ❑ Termina pplemental Preelection
(Also Complete Part 5) 0 Sponsored (Also file a Form 410 Termination) Statement-Attach Form 4515
General Purpose Committee (Also Complete Perth) ❑ Amendment (Explain below)
❑ 0 Sponsored r-1 Primarily Formed Candidate/
0 Small Contributor Committee Officeholder Committee
0 Political Party/Central Committee (Also Complete Pail 7) .......
3. CommitteeI.D. NUMBER Treasurer(s)
Information 11342226
COMMITTEE NAME(OR CANDIDATE'S NAME IF NO COMMITTEE) NAME O
erson for City Council 2012 Erik Peterson
MAILING ADDRESS
5122 B019a Avenue Ste. 107
STREET ADDRESS(NO P.O. BOX) CITY STATE ZIP CODE AREA cooFffld�')NE
5122 Bolsa. Avenue Ste. 107 Huntington Beach CA 92649 (714) 58061.iSO
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
Huntington Beach CA 92649 (714) 580-6980
MAILING ADDRESS(IF DIFFERENT) NO.AND STREET OR P.O. BOX MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA COnF!P-101,11F
OPTIONAL: FAX/E-MAIL ADDRESS OPTIONAL: FAX/E-MAIL ADDRESS
erikiDetersonhb@qmail.com
4. Verification
I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information Qg tamecLberei"ndin4he-attachedscheri s is true and complete. I certify
under penalty of perjury underthe lqwsofthe State of California that the foregoing is true and correct.
K2_
Executed on BY SignatureofTreagW L&sA ntTreasurer
Executed on. BY Date .94neffre of Controlling Offoeho der.T Candidate,State Measure Proponent or Responsible Officer of Sponsor
Executed on Date By Signature of Controlling Officeholder,Candidate,State Measure Proponent
Executed on Date By Signature of Controlling Officeholder,Candidate,State Measure Proponent FPPC Form 460(Jwiu-aryj06)
FPPC Toll-Free Helpline:8661ASK-FPPC(8613/276-3772)
statu 1:11;i.'.:aW<nt[Ia
Type or print in ink. COVER PAGE-PART 2
Recipient Committee CA-LIFORN IA
Campaign Statement i fbRM4611 ,,
Cover Page—Part 2
Page 2 of 7
6. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHO NAME OF BALLOT MEASURE
Erik Peterson
OFFICE SOUGHT OR HELD(INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) BALLOT NO.OR LETTER JURISDICTION ❑ SUPPORT
❑ OPPOSE
City Council Member
RESIDENTIAL/BUSINESS ADDRESS (NO.AND STREET) CITY STATE ZIP
5122 Bolsa Avenue Ste. 107 Identify the controlling officeholder, candidate, or state measure proponent, if any.
Huntington Beach CA 92649
NAME OF OFFICEHOLDER,CANDIDATE,OR PROPONENT
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 OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
contributions or make expenditures on behalf of your candidacy.
COMMITTEE NAME I.D. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE? 7. Primarily Formed Candidate/Officeholder Committee List names of
officeholder(s)or candidate($)for which this committee Ia primarily formed.
❑ YES ❑ NO
COMM117EE ADDRESS STREETADDRESS (NO P.O.BOX) NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT
❑ OPPOSE
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ SUPPORT
❑ OPPOSE
COMMITTEE NAME I.D. NUMBER
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT
❑ OPPOSE
NAME OF TREASURER CONTROLLED COMMITTEE? NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
❑ YES ❑ NO ❑ OPPOSE
T
COMMITTEE ADDRESS STREETADDRESS (NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE Attach continuation sheets if necessary
FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(86612763772)
State of California
Campaign Disclosure Statement Type or print in ink. SUMMARY PAGE
Amounts may be rounded Statement covers period , • -NIA
Summary Page to whole dollars. J
-
from 01/01/2012
SEE INSTRUCTIONS ON REVERSE
through 07/31/2012 Page 3 of 7
-
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012 1342226
ColumnA Column B Calendar Year Summary for Candidates
Contributions Received TOTALTHISPERIOD CALENDARYEAR
(FROM ATTACHED SCHEDULES) TOTALTO DATE Running in Both the State Primary and
General Elections
1. Monetary Contributions ............ Schedule A,Line 3 $ $7,170.00 $ $7,170.00
1/1 through 6130 7(1 to Date
2. Loans Received ..............•,...................................... schedule B,Linea
$0.00 $0.00
3. SUBTOTAL CASH CONTRIBUTIONS Add Lines 1+2 $ $7,170.00 $ $7,170.00 20. Contributions
Received $ $
4. Nonmonetary Contributions.................................... Schedu►eC,Linea $0.00 $0.00 21 Expenditures
5. TOTAL CONTRIBUTIONS RECEIVED •••... ...............AddLines3+4 $ $7,170.00 $ $7,170.00 Made $ $
Expenditures Made Expenditure Limit Summary for State
6. Payments Made....................................................... schedule E,Line 4 $ $0.00 $ $0.00 Candidates
7. Loans Made............................................................. ScheduleH,Linea $0.00 $0.00
22.Cumulative Expenditures Made*
8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6+7 $ $0.00 $ $0.00 (if Subimto Voluntary ExpenditureLimit)
9. Accrued Expenses (Unpaid Bills) ...............................schedule F,Line 3 $0.00 $0.00 Date of Election Total to Date
10. Nonmonetary Adjustment ..........................................schedu►ec,Linea
$0.00 $0.00 (mm/dd/yy)
11. TOTAL EXPENDITURES MADE................................Add Lines 8+9+10 $ $0.00 $ $0.00 $ -
Current Cash Statement $ -
12. Beginning Cash Balance....................... Previous summary Pape,Line 16 $ $359.42 To calculate Column B,add
13. Cash Receipts ............................. ..................... Column A,Line 3above $7,170.00 amounts In Column Atothe
corresponding amounts *Amounts in this section may be different from amounts
14. Miscellaneous Increases to Cash...................•....... schedule►,Line 4 $0.00
O.oo from Column B of your last reported in Column B.
15. Cash Payments................ .................. Column A,Line8above $0.00 report. Some amounts in
y Column A may be negative
16. ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ $7,529.42 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 A Part 2 $ $o.00 for this calendar year, only
carry over the amounts
Cash Equivalents and Outstanding Debts arny)Lines 2,�, and 9 (if
18. Cash Equivalents........................................ see instructions on reverse $ $0.00
19. Outstanding Debts......................... Add tine 2+Line 9 in Column B above $ $0.00 FPPC Form 460(January/06)
FPPC Toil-Free Helpline:866/ASK-FPPC(866/276-37'72)
Schedule A Type or print in ink. SCHEDULE A
Amounts may be rounded Statement covers period
Monetary Contributions received to whole dollars. CALIFORNIA , i
from 01/01/2012 •"
SEE INSTRUCTIONS ON REVERSE through 07/31/2012 Page 4 of 7
NAME OF FILER I.D. NUMBER
Erik Peterson for City Council 2012 1342226
FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
DATE FULL
(IFCOMMIE,ALSENTERI.D.NUMBER) CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE
MPLOYED,ENTER NAME PERIOD (JAN.1 -DEC.31) (IF REQUIRED)
OF BUSINESS)
06/15/2012 Troy Houston E)IND Attorney $250.00
18834 Coolwater Lane ❑COM Hodes Milana
❑OTH
Huntington Beach CA 92648 ❑PTY
❑SCC
06/16/2 e ®IND Self Employeed $520.00 $520.00 G12 $520.00
❑COM
6192 Forester drive ❑OTH Investment Anaalyst
Hunti 2548 [:]PTY
❑SCC
06/16/2012 Michael Gates ®IND Attorney $250.00 $250.00 G12 $250.00
16152 Tyee Lane ❑OTH Sullivan, Bauoa, &
❑PTY Williams
Huntington Beach CA 92647 ❑SCC
06/16/2012 Intec ❑IND $500.00 $500.00 G10 $400.00
❑COM G12 $500.00
251D Warren Ave MOTH
Cheyenne WY 82001 ❑PTY
❑SCC
06/16/2012 David Keough ®IND Alent, Inc. $200.00 $200.00 G12 $200.00
❑ Manger
COM o eratons Man
8792 Cliffside Drive ❑OTH p g
Huntington Beach CA 92546 [:]PTY
❑SCC
SUBTOTAL$ $1,720.00
Schedule A Summary 'Contributor Codes
1. Amount received this period—itemized monetary contributions. IND-Individual
(include all Schedule A subtotals.) .................. $ $6,820.00 COM-RecipientCommittee
(other than PTY or SCC)
2. Amount received this eriod—unitemized monetary contributions of less than$100 ............................. $ $350.00 OTH-Other(e.g., business entity)
P rY PTY-Political Party
3. Total monetary contributions received this period. SCC-Small contributor committee
Add Lines 1 and 2. Enter here and on the SummaryA 1. ..... TOTAL $ $7,170.00
( Page, Column , Line )������������������ FPPC Form 460(January/05)
FPPC Toll-Free Helpline:866/ASK-FPPC(866/276-3772)
Schedule A (Continuation Sheet) Type or print in ink. SCHEDULE A (CONT)
Monetary Contributions Received Amounts may be rounded Statement covers period ® .
to whole dollars.
from 01/01/2012 • "
through 07/31/2012 page 5 of 7
NAME OF FILER
I.D,NUMBER
Erik Peterson for City Council 2012 1342226
DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
RECEIVED (IF COMMITTEE,ALSAND ZIP
I.D.CODE O CODE * OCCUPATION AND EMPLOYER RECE LENDAR YEAR TO DATE
(IF SELF-EMPLOYED,ENTER NAME PERIOD (JAN.1 -DEC,31) (IF REQUIRED)
CF BUSINESS)
06/1 ®I ND Dentist $100.00 $100.00 G12 $100.00
17215 Almelo Lane ❑COM Self❑OTH
Huntington Beach CA 92649 ❑PTY
/2D12 Scott Sailers ®IND Police Officer $100.00 $100.00 G12 $100.00
❑COM
17562 Wrightwood Lane ill Police
❑PTY Department
Huntington Beach CA 92649 ❑SCC
06/17/2012 Thomas Maloney ®IND Retired $200.00
❑COM
1436 Brixton Road ❑OTH R®tired
Pasadena CA 91105 ❑PTY
❑SCC
06/25/2012 Intec Network Solutions, Inc. MIND $520.00 $520.00 G12 $520.00
❑COM
5122 Bolsa Ave. suite 107 Q OTH
Huntington Beach CA 92649 ❑PTY
❑SCC
07/02/2012 Jack's Surf & Sport, LLC ❑IND $520.00 $520.00 G10 $500.00
❑COM G12 $520.00
16350 Gothard suite 101 ®OTH
Huntington Beach CA 92647 ❑PTY
❑SCC
SUBTOTAL$ $1,440.00
*Contributor Codes
IND—Individual
COM—Recipient Committee
(other than PTY or SCC)
OTH—Other(e.g., business entity)
PTY—Political Party FPPC Form 460(January/06)
SCC—Small Contributor Committee FPPC Toll-Free Helpline:866/ASK-FPPC(866/276-3772)
Schedule A (Continuation Sheet) Type or print in ink. SCHEDULE A (CONT)
Monetary Contributions Received Amounts may be rounded Statement covers period FPage
to whole dollars. from O1/O1/2012 through 07/31/2012 of 7
NAME OF FILER I.D.NUMBER
Erik Peterson for City council 2012 1342226
DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
RECEIVED (IFCOMMITTEE,ALSOENTERID,NUMBER) CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE
(IF SELF-EMPLOYED,ENTER N.1 -DEC.31) (IF REQUIRED)
OF BUSINESS)
07/16/2012 Bob Jones ®IND owner $520.00 $520.00 G12 $520.00
7071 Warner Ave. # TH Performance Network
FIFTY
Solutions
Huntington Beach CA 92647 ❑SCC
07/16/2012 U•S $520.00 $520.00 G10 $520.00
❑COM G12 $520.00
16702 Producer Lane ®OTH
Huntington Beach CA
07/17/2012 John Freeman ®IND Retired $100.00 $100.00 G10 $100.00
G12 $100.00
178$2 Romell H Retired
Santa Ana CA 92705 ❑PTY
❑SCC
07/18/2012 Susan Jervik MIND Nurse $100.00 $100.00 G10 $250.00
G12 $100.00
15391 Cambay Lanet ncm❑OpH Whittier Hospital
Huntington Beach CA 92649 ❑PTY
❑SCC
07/19/2012 Greg Resnokoff ®IND Owner $500.00 $500.00 G12 $500.00
3842 Seascape Drive ❑COM❑OTH Beach Wire & Cable
Huntington Beach CA 92649 ❑PTY
❑SCC
SUBTOTAL$ $1,740.00
"Contributor Codes
IND—Individual
COM—Recipient Committee
(other than PTY or SCC)
OTH—Other(e.g., business entity)
PTY—Political Party FPPC Form 460(January/05)
SCC—Small Contributor Committee FPPC Toll-Free Helpline:866/ASK-FPPC(866/276-3772)
Schedule A (Continuation Sheet) Type or print in ink. SCHEDULE A (CONT.)
Monetary Contributions Received Amounts may be rounded Statement covers period
to whole dollars. I ,
from 01/01/2012 • "
through 07/31/2012 Page 7 of 7
NAME OF FILER I.D.NUMBER
Erik Peterson for City Council 2012 1342226
DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION
RECEIVED ( COMMITTEE,ALSO ENTER I.D.NUMB CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE
(IF SELF-EMPLOYED,ENTER NAM D (JAN.1 -DEC.31) (IF REQUIRED)
OF BUSINESS)
07/24/2012 Committee to re-elect Congressman Dana ❑IND $500.00 $500.00 G
Rohrabacher ❑COM
Po Box 823 MOTH
Huntington Beach CA 92648 ❑PTY
❑SCC
07/30/2012 Dorothy Seldy tired $400.00 $400.00 G10 $520.00
❑COM G12 $400.00
17881 Felson Cir ❑OTH Reti
ngton Beach CA 92649 ❑PTY
❑SCC
07/31/2012 Richard Moore MIND Program Manager $520.00 $520.00 G12 $520.00
6921 Canterbury Dive ❑COM❑OTH Molina Health Care
Huntington Beach CA 92647 ❑PTY
❑SCC
07/31/2012 SMI Technologies ❑IND $500.00 $500.00 G12 $500.00
❑COM
2510 Warren Ave ❑% OTH
Cheyenne WY 82001 ❑PTY
❑SCC
❑IND
❑COM
❑OTH
❑PTY
❑SCC
SUBTOTAL$ $1,920.00
'Contributor Codes
IND-Individual
COM-Recipient Committee
(other than PTY or SCC)
OTH-Other(e.g., business entity)
PTY-Political Party FPPC Form 460(January/05)
SCC-Small Contributor Committee
FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772)