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HomeMy WebLinkAboutPolsky, Alexander S. - 2012 FPPC Campaign Disclosure Forms f (2) Type or print in ink. SUMMARY PAGE Campaign Disclosure Statement Amounts may be rounded Statement covers period Summary Page ® a ° to whole dollars. (?y --��( b � � .yam from through � i. "' 1 Page of� SEE INSTRUCTIONS ON REVERSE I.D. NUMBER NAME OF FILER s .� ��� �..J� � J b31�� �L Column A Column B Calendar Year Summary for Candidates Contributions Received TOTAL THIS PERIOD CALENDAR YEAR Runnin in Both the State Primary and (FROM ATTACHED SCHEDULES) T--OT DATE General Elections 1. Monetary Contributions ........................................... schedule A.Line 3 $ �t� $ 1/1 through 6/30 7/1 to Date 2. Loans Received ...................................................... schedule e,Line 3 C) ` 20. Contributions 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1+2 $ $ Received $ $ 4. Nonmonetary Contributions.................................... Schedule C,Line 3 - z 21, Expenditures 7 Made $ $ 1 5. TOTAL CONTRIBUTIONS RECEIVED ...........................Add Lines 3+4 $ $ -- Expenditures Made (> } Expenditure Limit Summary for State 6. Payments Made....................................................... schedule E,Line 4 $ $ c�/ Candidates 7. Loans Made............................................................. Schedule H.Line 3 22. Cumulative Expenditures Made" 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6+7 $ $ (If Subject to Voluntary Expenditure Limit) 9. Accrued Expenses (Unpaid Bills) ...............................Schedule F Line 3 Date of Election Total to Date (mm/ddiyy) 10. Nonmonetary Adjustment ..........................................schedule C,Line 3 11. TOTAL EXPENDITURES MADE................................Add Lines s+9+ 10 $ $ 71 $ Current Cash Statement 12. Beginning Cash Balance....................... Previous Summary Page,Line 16 $ To calculate Column B,add amounts in Column A to the $ 13. Cash Receipts ................................................... Column A,Line 3 above corresponding amounts 14. Miscellaneous Increases to Cash.......................... Schedule 1,Line 4 from Column B of your last $ C� i report. Some amounts in 15.Cash Payments.................................................. Column A,Line 8 above Column A may be negative $ 16. ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ 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 $ for this calendar year, only carry over the amounts 'Since January 1,2001. Amounts in this section may be from Lines 2,7, and (if different from amounts reported in Column B. Cash Equivalents and Outstanding Debts any). 18. Cash Equivalents......____........................ see instructions on reverse $ - - 19. Outstanding Debts......................... Add Line 2+Line 9 in Column a above $ FPPC Form 46Q FPPC Toll-Free Helpline: 866/ASK-FPPC-FPPC Lugar, Robin From: Lugar, Robin Sent: Tuesday, January 29, 2013 2:51 PM To: 'ellen polsky' Cc: Flynn, Joan Subject: RE: Fwd: Semi-Annual 460 Filing- Huntington Beach Attachments: FPPC Chapter 8.pdf Hi Ellen, Yes, you are required to file a copy of your termination statement with your local office (City Clerk). We did not receive this. Also, when you terminate you must file a 460 Termination statement to show the disposition of your committee's campaign funds. See Chapter 8 —After the Election(attached) for details on how to appropriately terminate a campaign committee. Questions should be directed to the FPPC. Robin Estanislau, CMC Assistant City Clerk City of Huntington Beach 2000 Main Street Huntington Beach CA 92648 (714) 536-5405 From: ellen polsky [mailto:epolsky@yahoo.com] Sent: Tuesday, January 29, 2013 2:27 PM To: Lugar, Robin Cc: alex polsky Subject: Fw: Fwd: Semi-Annual 460 Filing - Huntington Beach Hi Robin, it's me again I filed the termination with the Secretary of state on 12-3. There wasn't anything that stated I had to file with you all so I didn't. I have a copy of the 410. What do I need to do? As always...... Thank you. Ellen ----- Forwarded Message----- From: Alexpolsky<alexpolsky@polskymediation.com> To: ellen polsky<epolsky@yahoo.com> Sent: Tuesday, January 29, 2013 11:48 AM Subject: Fwd: Semi-Annual 460 Filing - Huntington Beach From I Pad of Alexander S Polsky, Mediator/Arbitrator, JAMS. Professor of Law,Negotiation/ADR, USC. 714 501 1321. Case manager, Laura Aguilar 714 937 8256. Content confidential to intended recipient(s). Begin forwarded message: From: "Lugar, Robin" <rlu ag_rgsurfcity-hb.org> Date: January 29, 2013, 11:37:12 AM PST To: Alexpolsky<alexpolskygpolskymediation.com> 1 Cc: "Flynn, Joan" <jflynnksurfcit. -hb.org> Subject: RE: Semi-Annual 460 Filing-Huntington Beach Yes ... as long as your committee remains open you must file according to the deadline schedule provided above. If you wish to terminate your committee, you must file a 410 Termination Statement with the California Secretary of State, and a 460 Termination Statement with the Huntington Beach City Clerk. Our records indicate that you failed to file a 460 Pre-election Statement for the following period: Oct 25,2012 10/1/12—10/20/12 460 ■ All committees must Pre-Election file this report. I have attached your committee file for your review. If you need advice on bringing your campaign committee filings current, including termination, contact the FPPC at 1-866-ASK- FPPC, or send an inquiry to the staff help email address at adviceg- ncTca. oovv. Robin Estanislau, CMC Assistant City Clerk City of Huntington Beach 2000 Main Street Huntington Beach CA 92648 (714)536-5405 From: Alexpolsky[mailto:alexpolskyg_polskymediation.com] Sent: Tuesday,January 29,2013 11:12 AM To: Lugar,Robin Cc: ellen polsky Subject: Re: Semi-Annual 460 Filing-Huntington Beach me? From I Pad of Alexander S Polsky, Mediator/Arbitrator, JAMS. Professor of Law, Negotiation/ADR, USC. 714 501 1321. Case manager, Laura Aguilar 714 937 8256. Content confidential to intended recipient(s). On Jan 29, 2013, at 10:31 AM, "Lugar, Robin" <rlugarAsurfcithb.org>wrote: Reminder ... Thursday, January 3Is'at 5:00 PM is the deadline to file your semi- annual 460 forms with the Huntington Beach City Clerk(see attached). Robin Estanislau, CMC Assistant City Clerk City of Huntington Beach 2900 Main Street Huntington Beach CA 92648 ('714)536-5405 <Local Candidate-Committee FPPC Filing Schedule 2012.pdf> 2 • STATEMENT OF ORGANIZATION Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Page 3 I .NUMBER COMMITTEE NAME 4.Type of Committee (Continued) .o . Not formed to support or oppose specific candidates or measures in a single election. Check only one box: ❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY r`.• ,' List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREETADDRESS NO.AND STREET CITY STATE ZIP CODE 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 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. -- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511 - 89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5. FPPC Form 410 (April/2011) FPPC Toll-Free Nelpline: 866/ASK-FPPC (866/275.3772) STATEMENT OF ORGANIZATION Statement of Organization JFPage • • ,Recipient Committee INSTRUCTIONS ON REVERSE 2 . .NUMBER COMMITTEE NAME 4.Type of Committee Complete the applicable sections. a o •s • • 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. ELECTIVE OFFICE SOUGHT OR HELD YEAR OF ELECTION PARTY NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLI Non-Partisan ❑ 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 CITY STATE ZIP CODE ADDRESS Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION CANDIDATE(S)NAME OR MEASURE(S)FULL TITLE(INCLUDE BALLOT NO.OR LETTER) (INCLUDE DISTRICT NO.,CITY OR COUNTY,AS APPLICABLE) SUPPORT CHECK ONE N POSE I ) SUPPORT OPPOSE FPPC Form 410 (Junel09) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/276-3772) ,�tateB`>t'lent Of Organization IFORNISTATEMENT OF ORGANIZATION Recipient Committee R l a � INSTRUCTIONS ON REVERSE Page Recipient I.D.NUMBER COMMITTEE N ME 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 n COUNTY Committee ❑STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY ® •, ® List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREETADDRESS NO.AND STREET CITY STATE ZIP CODE 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 met: e 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 e 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. -- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511 - 89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5. FPPC Form 410 (June/09) FPPC Toll-Free Helpline: 866IASK-FPPC(8661275-3772) COVER PAGE Recipient Committee Type or print in Ink. Date Stamp Campaign Statement Cover Page E-filed on: 10/01/2012 21:12:01 Government Code Sections 84200-84216.5) Statement covers period Date of election if applicable: dage— 1 of 4 38853738 from 07/01/2012 (Month, Day, Year) 2012 OCT I I P 11 1: For Official Use Only 3EE 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: Fx� Officeholder,Candidate Controlled Committee F-1 Primarily Formed Ballot Measure Fx-1 Preelection Statement ❑ Quarterly Statement 0 State Candidate Election Committee Committee [:] Semi-annual Statement ❑ Special Odd-Year Report 0 Recall 0 Controlled Fj Termination Statement ❑ Supplemental Preelection (Also Complete Part 5) 0 Sponsored ❑ (Also file a Form 410 Termination) Statement-Attach Form 495 ❑ General Purpose Committee (Also Complete Part 6) E] Amendment(Explain below) 0 Sponsored F-1 Primarily Formed Candidate/ 0 Small Contributor Committee Officeholder Committee 0 Political Party/Central Committee (Also C . Committee Information I.D. NUMBER Treasurer(s) IPending COMMITTEE NAME(OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER Polsky for City Council 2012 Alexander Polsky MAILING ADDRESS ds Lane STREET ADDRESS (NO P.O.,BOX) CITY STATE ZIP CODE AREA CODE/PHONE 19346 Woodlands Lane Huntington Beach CA 92648 (714) 501-1321 CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY Huntington Beach CA 92648 (714) 501-1321 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 Alexpolskv@polskymediation.com alex2olsky@polskymediation.com 1. Verification I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the inform 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 10/01/2012 By Date — Si D Treas Assistant Treasurer Executed on — 1 ) Z By Date Signature of ControftZifficelhold el,State ure Proponent or Responsible Officer of Sponsor Executed on By Cate Signature of Controlling Elder,CandidaterSMe-Measure Proponent Executed on By Date Signature of CoMrrolling Officeholder,Cqli§aaWy,19Fate Measure Propo FPPC Form 460(January/0.1 FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-377A 7�� State of Callforni Type or print in ink. COVER PAGE-PART 2 Recipient Committee Campaign Statement ® . Cover Page— Part 2 Page 2 of 4 i. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee NAME OF OFFICEHOLDER OR CANDIDATE NAME OF BALLOT der Polsky 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 19364 woodlands Lane Identify the controlling officeholder, candidate, or State measure proponent, if any. Huntington Beach CA 92648 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/Of FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-377: State of Californi Type or print in ink. SUMMARY PAGI ;ampaign Disclosure Statement Amounts may be rounded Statement covers period;t6mmaE")/ age to whole dollars. from07/01/2012 through 09/30/2012 IBMage 3 ;EE INSTRUCTIONS ON REVERSE I,D. NUMBER IAME OF FILER ,olsky for City Council 2012 Pending Column A Column B Calendar Year Summary for Candidates ..ontributions Received TOTALTH DSCHED CALENDA DATE Runningin Both the State Primary and (FROM ATTACHEDSCHEUULES) TOTALTODATE General Elections Monetary Contributions ........................................... Schedule A,Line 3 $ $0.00 $ _ $0.00 1/1 through 6/30 7/1 to Date $9,961.00 $9,981.00 Loans Received ...................................................... Schedule B,Line 3 $9,981.00 $9,981..00 20. Contributions I, SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1+2 $ $ Received $ $--- - Nonmonetary Contributions.................................... Schedule C,Line 3 $0.00 $0'00 21. Expenditures i. TOTAL CONTRIBUTIONS RECEIVED ...........................Add Lines 3+4 $ $9,981.00 $ $9,981.00 Made $ $ Xpenditures Made Expenditure Limit Summary for State i. Payments Made................ Schedule E,Line 4 $ $0.00 $ $0.00 Candidates Loans Made............................................................. Schedule $0.00 $0.00 22. Cumulative Expenditures Made* I. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6+7 $ $0.00 $ $0.00 (If Subject to Voluntary Expenditure Limit) I. Accrued Expenses (Unpaid Bills) ...............................Schedule F Line 3 $0.00 - $0.00 Date of Election Total to Date 0. Nonmonetary Adjustment ..........................................Schedule C,Line 3 $0.00 $0.00 (mm/dd/yy) 1. TOTAL EXPENDITURES MADE.................................AddLines 8+s+10 $ $0•00 $ _ $0.00 $ :urrent Cash Statement $ 2. Beginning Cash Balance....................... Previous Summary Page,Line 16 $ $0.00 To calculate Column B,add 3. Cash Receipts ........................... Column A,Line 3 above $9,981.00 amounts in Column A to the corresponding amounts *Amounts in this section may be different from amounts 4.Miscellaneous Increases to Cash........................... Schedule/,Line 4 $0.00 from Column B of your last reported in Column B. $0.00 report. Some amounts in 5. Cash Payments.................................................. Column A,Line 8 above Column A may be negative 6. ENDING CASH BALANCE.......... Add Lines 12+13+14,then subtract Line 15 $ $9,961-00 figures that should besubtracted from previous If this is a termination statement, Line 16 must be zero. period amounts. if this is the first report being filed Schedule a,Part $ $0.00 for this calendar year, only 7. LOAN GUARANTEES RECEIVED .......................... carry over the amounts from Lines 2, 7, and 9(if :ash Equivalents and Outstanding Debts $0.00 any) 8. Cash Equivalents........................................ See instructions on reverse $ $9 981.00 FPPC Form 460(Januaryl0� 9. Outstanding Debts.............. ,........... Add Line 2+line 9 in Column B above $ FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772 SCHEDULEB-PART' Type or print in ink. ichedule B—Part 1 Amounts may be rounded Statement covers period m .®ans Received to whole dollars. from 07/01/2012oll through 09/30/2012 page 4 of 4 EE INSTRUCTIONS ON REVERSE ID. NUMBER AME OF FILER olsky for City Council 2012 Pending IF AN INDIVIDUAL, ENTER a (b) (c) (d) (e) If) UL FULL NAME,STREET ADDRESS AND ZIP CODE OUTSTANDING AMOUNT AMOUNT PAID OUTSTANDING INTEREST ORIGINAL CUMULATIVE OCCUPATION AND EMPLOYER BALANCE BALANCEAT OF LENDER f ECEIVED THIS OR FORGIVEN (IF SELF-EMPLOYED, CLOSE OF THIS PAID THIS AMOUNT OF CONTRIBUTION; D,ENTER BEGINNING THIS PE PERIOD LOAN TO DATE (IF COMMITTEE.ALSO ENTER LD.NUMBER) NAME OF OF BUSINESS) pE THIS PERIOD PEBIQQ 4r. Alexander Polsky Mediator/Arbitrator ©PAID CALENDARYEAR (Self $9,981.00 0.00 $� $ $9,981.00 $ $9,981.01 S $ -9346 Woodlands Ln ❑FORGIVEN RATE PER ELECTION' $o.00 $9,9a1.00 10/O1/2012 $ 07/O1/2012 iuntington beach CA 92648 $ $ $_ ® IND ❑ COM ❑ OTH El PTY ❑ SCC DATE DUE DATE INCURRED ❑PAID CALENDARYEAR A $ % $ $ ❑FORGIVEN RATE PERELECTION* $ $ > $ $ DATE DUE DATE INCURRED ❑ IND ❑ COM ❑ OTH [:1 PTY ❑ SCC ❑PAID CALENDARYEAR S $ % $ $— E]FORGIVEN RATE PERELECTION* 1 $ ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED SUBTOTALS $ $9,981.00$ $0.00$ $9,981.00$ $o 00 (Enter_(.) on Schedule S Summary SrheduleE,Line 3) Loans received this period......................... .. . . .. . . $ $9,981.00 (Total Column(b)plus unitemized loans of less than$100.) tcontributor codes IND-Individual Loans paid or forgiven this period ......................................................... ............................................. $ $0.00 COM-Recipient Committee (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 , business entity) Party PTY-Politicall P Party Net change this period. Subtract Line 2 from Line 1. ................................................ NET $ $9,981.00 SCC-Small Contributor Committee g p ( " ' (May be a negative number) Enter the net here and on the Summary Page, Column A, Line 2. *Amounts forgiven or paid by another party also must be reported on Schedule A. **If required. FPPC Form 460(January/Of FPPC Toll-Free Helpline:866/ASK-FPPC(8661275-3772 Statement of Organization Type or print in ink STATEMENT OF ORGANIZATION Date Stamp Recipient Committee Statement Type Initial El Amendment ❑ Termination—See Par tt (� — For Official Use Only Not yet qualified or List I.D.number: List I.D.number: —JJ Date qualified as committee Date qualified as committee Date of Termination Committee Information 2. Treasurer and Other Principal Officers NAME OF COMMITTEE ` yJ NAME OF TREASURER STREET ADDRESS(NO P.O.BOX) /0" z STREETADDRESS(NO P.O.BOX) CITY STATE ZIP CODE AREA CODE/PHONE Jam/ � ��i'C�'o ��'��+•-r�'1'- �✓�7 CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY STREET ADDRESS(NO P.O.BOX) MAILING ADDRESS(IF DIFFERENT) CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL: FAX/E-MAILADD ESS � / p/� `�(� Ct����r✓� /;�T_�Cr�� ��1,�aj NAME OF PRINCIPAL OFFICER(S) COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE STREET ADDRESS(NO P.O.BOX) C� CITY STATE ZIP CODE AREA CODE/PHONE Attach additional information on appropriately labeled continuation sheets. 3. Verification I have used all reasonable diligence in preparing this statement and to the best of my knowl he i armation contained herein 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 -2— Z �Z By DATE SIG ATU URER OR ASSISTANT TREASURER - - 2 "'-' Executed on By DATE SIGNATURE O ROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT FPPC Form 410 (Apri112011) FPPC Toll-Free Helpline: 866/ASK-FPPC (8661276-3772) Statement of Organization STATEMENT OF ORGANIZATION Recipient Committee e � INSTRUCTIONS ON REVERSE Page 2 COMMITTEE NAME I.D.NUMBER 4.Type of Committee 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." • If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. ELECTIVE OFFICE SOUGHT OR HELD NAME/OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IFAPPLICABLE) YEAR OF ELECTION PARTY r Non-Partisan ❑ 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 o 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 SOUGHT OR HELD OR MEASURE(S)JURISDICTION (INCLUDE DISTRICT NO.,CITY OR COUNTY,AS APPLICABLE) CHECK ONE SUPPORT OPPOSE SUPPORT OPPOSE FPPC Form 410 (April/2011) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/276-3772) Statement of Organization STATEMENT OF ORGANIZATION Recipient Committee INSTRUCTIONS ON REVERSE Page 3 COMMITTEE NAME I.D.NUMBER 4.Type of Committee (Continued) RISE,110•. M" . Not formed to support or oppose specific candidates or measures in a single election. Check only one box: ❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY . -. . List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREETADDRESS NO.AND STREET CITY STATE ZIP CODE o • . o ❑ 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 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. -- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511 - 89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5. FPPC Form 410 (April/2011) FPPC Toll-Free Helpline: 666/ASK-FPPC (866/275-3772) CANDIDATE INTENTION STATEMENT Candidate Intention Statement Type or Print in Ink. l Date tarnp ffiFor q0nly E i" 7` t Officia Check One: 2012 �I � W (t�nitial ❑Amendment (Explain) 1. Candidate Information: NAME OF CANDIDATE (Last,First,Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER(optional) E-MAIL(optional) STREET ADDRESS CITY STATE ZIP CODE ¢ �� OFFICE SOUGHT(POSITION TITLE) AGENCY/NAME DISTRICT NUMBER,if applicable. ON-PARTISAN If- �/ C��4G+C. 1/ /-- PARTY: OFFICE JURISDICTION ❑ State (Complete Part 2.) ® r �Clty [I County ❑ Multi-County: (Name of Multi-County,Jurisdiction) (Year of Election) 2. State Candidate Expenditure Limit Statement: (Ca1PERS and CaISTRS candidates,judges,judicial candidates, and candidates for local offices do not complete Part 2.) (Year of Election) (Year of Election)Primary/general election Special/runoff election (Check one box) ❑ I accept the voluntary expenditure ceiling for the election stated above. ❑I do not accept the voluntary expenditure ceiling for the election stated above. Amendment: O t did not exceed the expenditure ceiling in the primary or special election held on: and I accept the voluntary expenditure ceiling for the general or special run-off election. (Mark if applicable) ❑ On I contributed personal funds in excess of the expenditure ceiling for the election stated above. 3. Verification: I certify under penalty of perjury under the laws of the State of California that the foreg!�jrc,:ts-trt e'and correct. Executed on 27J e, Z Signature (month,day.year) (Candidate) FPPC Form 501 (April/2011) FPPC Toll-Free Helpline:8661ASK-FPPC(866/275-3772)