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HomeMy WebLinkAboutForm 460 Sandy Jack for Atascadero City Council - 2010 12312010Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200-84216.5) Type or prink in ink. Dexo sxamp RECEIVE COWER PAGE Statement covers pa riod Data of election if applicable: ,JAN 2 8 2010 Page ofd from 12/23/09 (Month, Day Year)) For official use only SEE INSTRUCTIONS ON REVERSE 1 through „/�,/rlA ITY OF ATAS CAOER 1 Type of Recipient Committee All Committees — COTFIete Farts 1, 2, 3, and 4. ® Officeholder Candidate Controlled Committee Q Primarily Formed Ballot Measure Q State Candidate Election Committee Committee Q Recall Q Controlled (A/SO Compare Parr SJ Q Sponsored Atascadero (A/30 COmpbfa Part B) Q General Purpose Committee MAILING Ap ORE55 (IF pIFFERENT) NO ANO STREET OR PO BOX Q Sponsored Primarily Formed Candidate/ Q Small Contributor Committee Officeholder Committee Q Political Party/Central Committee (A/so Comp/afa PBR 7) 3. Committee Information Lp NUMBER '1323307 COMMITTEE NAME (OR CAN OIpATE'S NAME IF NO COMMITTEE) Sandy Jack for Atascadero City Council 2010 STREET AOpRE55 (NO PO BOX) CITY STATE ZIP COPE AREA COpE/PHONE Atascadero Ca 93422 MAILING Ap ORE55 (IF pIFFERENT) NO ANO STREET OR PO BOX CITY STATE ZIP COpE AREA COp E/PHONE OPTIONAL: FAX / E-MAIL AppRE55 lit 1 Y liLCl"I K'.7 Vrrll:C 2- Type of Statement= Q Praalaction Statement Q Quarterly Statement ® Sami-annual Statement Special Odd -Year Report Q Termination Statement Q Supplemental Preelection (Also file a Form 410 Termination) Statement Attach Form 495 Q Amendment (Explain below) Trees u re r(s) NAME OF TREASURER David P Bentz MAILING App RE55 d CITY STATE ZIP CO AREA CODE/PHONE AtascadBro Ca 93422 NAME OF ASSISTANT TREASURER. IF ANV MAILING App RE55 CITV STATE ZIP COnE AREA CODE/PHONE OPTIONAL: FAX / E-MAIL App RE55 4. Verification 1 have used all reasonable diligence m preparing and reviewing this statement and to the best of my knowledge the information contained herein and m the attached schedules is true and complete. 1 certify under penalty of perjury under the laws of the State of California that the foregoing is true a orr t. Executed on 01/12/2010 By Data si stent Traaa<.rer Executed on 01/12/2010 By re aur pato atu of Con[rolling der. Candida q Sta a Pmponant or Raxponalbla OToar oT Sponsor Executed on para By Slgnaturn of Controlling OT(Icaholdar Candidata. State Measure Proponent Executetl on paw By s�g.,a<u.e o<controuing otticanoluer Car.dlGa<a, state Massu,a Propor.ara FFFC Form Aso (January/os) FFFC Toll -Free Helpline: 866/A SK-FFFC (866/275-3772) State of CaOfornla Type or print in ink. Recipient Committee Campaign Statement Cover Page — Part 2 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Sandy Jack OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) City Councilman, Atascadero, Ca RESIDENTIAUBUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP -_ Atascadero, Ca 93422 Related Committees Not Included in this Statement' List any committees not included in this statement that are controlled by you or are primarily formed to receive contributions or make expenditures on behalf of your candidacy COMMITTEE NAME LD NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? ❑ YES ❑ NO COMMITTEE ADDRESS STREETADDRESS (NO PO BOX) CITY STATE ZIP CODE AREA CODE/PHONE COMMITTEE NAME I.D. NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? ❑ YES ❑ NO COVER PAGE PART 2 Page A of 4 6. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE BALLOT NO OR LETTER JURISDICTION ❑ SUPPORT ❑ OPPOSE Identify the controlling officeholder, candidate, or state measure proponent, if any NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT OFFICE SOUGHT OR HELD DISTRICT NO IF ANY 7 Primarily Formed Candidate/Officeholder Committee List names of officeholder(s) or candidate(s) for which this committee is primarily formed. COMMITTEE ADDRESS STREETADDRESS (NO PO BOX) CITY STATE ZIP CODE AREA CODE/PHONE Attach continuation sheets if necessary NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE 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 - 1 Summary Page to whole dollars. • from 12/23/09 , > page -� of through 12/31/09 SEE INSTRUCTIONS ON REVERSE NAME OF FILER I.D. NUMBER Sandy Jack for Atascadero City Council 2010 11323307 Column A Column B Calendar Year Summary for Candidates Contributions Received TOTALTHIS PERIOD CALENDAR YEAR Primary Running in Both the State Prima and (FROMATTACHED SCHEDULES) TOTALTO DATE General Elections 1 Monetary Contributions Schedule A, Line 3 $ 00 $ 00 1/1 through 6/30 7/1 to Date 600000 6000 00 2. Loans Received Schedule B, Line 3 600000 $ 600000 20 Contributions 3. SUBTOTALCASH CONTRIBUTIONS Add Lines 1 +2 $ Received $ $ 00 00 4 Nonmoneta Contributions Schedule C, Line 3 ry 21 Expenditures +4 $ 600000 $ 600000 Made $ $ 5. TOTAL CONTRIBUTIONS RECEIVED Add Lines 3 Expenditures Made Expenditure Limit Summary for State 6. Payments Made Schedule E, Line 4 $ 00 $ 00 Candidates 7 Loans Made Schedule H, Line 3 00 00 22. Cumulative Expenditures Made* 8. SUBTOTAL CASH PAYMENTS Add Lines 6 + 7 $ 00 $ 00 (if Subject to Voluntary Expenditure Limit) 9 Accrued Expenses (Unpaid Bills) Schedule F Line 3 00 00 Date of Election Total to Date 00 00 (mm/dd/yy) 10 Nonmonetary Adjustment Schedule C, Linea 11 TOTAL EXPENDITURES MADE Add Lines 8 + 9 + 10 $ 00 $ 00 J $ —�� $ Current Cash Statement 12. Beginning Cash Balance Previous Summary Page, Line 16 $ 00 To calculate Column B, add 13. Cash Receipts Column A, Line 3 above 600000 amounts in Column A to the 00 corresponding amounts Amounts in this section may be different from amounts 14 Miscellaneous Increases to Cash Schedule 1, Line 4 from Column B of your last reported in Column B. 00 report. Some amounts in 15 Cash Payments Column A, Line 8 above y Column A may be negative 16. ENDING CASH BALANCE Add Lines 12 + 13 + 14, then subtract Line 15 $ 600000 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 for this calendar year only 00 17 LOAN GUARANTEES RECEIVED Schedule A Part 2 $ carry over the amounts fromLines 2, 7 and 9 (if Cash Equivalents and Outstanding Debts 18 Cash Equivalents See instructions on reverse 00 $ $ 600000 FPPC Form 460 (January/05) 19 Outstanding Debts Add Line 2 + Line 9 in Column B above FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) SCHEDULE B PART 1 YF.�"� Schedule B — Part 1 Amounts may be rounded Statement covers period • - Loans Received to whole dollars. 12/23/09 • ' - from Page �L of 12/31/09 SEE INSTRUCTIONS ON REVERSE through NAME OF FILER I.D. NUMBER Sandy Jack for Atascadero City Council 2010 1323307 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUALENTER , a OUTSTANDING (b) AMOUNTAMOUNT (c) PAID (d) OUTSTANDING BALANCE AT (e) INTEREST (f) ORIGINAL (g) CUMULATIVE OF LENDER OCCUPATION AND EMPLOYER EN (IFSELF-EMPLOYED, ENTER BALANCE BEGINNING THIS RECEIVED THIS OR FORGIVEN CLOSE OF THIS PAID THIS AMOUNT OF CONTRIBUTIONS TO DATE (IF COMMITTEE, ALSO ENTER I.D. NUMBER) NAMEOFBUSI D PERIOD THIS PERIOD" p PERIOD LOAN ❑ PAID CALENDARYEAR Sandy Jack Retired $ 00 $ 600000 O 600000 $ 600000 8250 San Diego Rd % $ FORGIVEN E] FORGIVEN PER ELECTION Atascadero, Ca 93422 $ 00 600000 00 Demand $ 00 12/23/09 $ $ $ DATE DUE DATE INCURRED t2 IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ PAID CALENDARYEAR ❑ FORGIVEN PER ELECTION** RATE DATE DUE DATE INCURRED t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ PAID CALENDAR YEAR ❑ FORGIVEN PER ELECTION"* RATE DATE DUE DATE INCURRED tEl IND ❑ COM ❑ OTH ❑ PTY ❑ SCC SUBTOTALS $ 6000 00 $ 00 $ 600000 $ 00 Schedule B Summary 1 Loans received this period (Total Column (b) plus unitemized loans of less than $100 ) 2. Loans paid or forgiven this period (Total Column (c) plus loans under $100 paid or forgiven.) (Include loans paid by a third party that are also itemized on Schedule A.) 3 Net change this period. (Subtract Line 2 from Line 1 ) Enter the net here and on the Summary Page, Column A, Line 2 (Enter (e) on Schedule E, Line 3) $ 600000 $ NET $ 600000 (May be a negative number) tContributor Codes IND—Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY—Political Party SCC — Small Contributor Committee 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 (8661275-3772) Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200-84216.5) SEE INSTRUCTIONS ON REVERSE Type or print in ink. Statement covers period from 01/01/2010 through 01/12/2010 1 Type of Recipient Committee All Committees — Complete Parts 1 2, 3, and 4. ® Officeholder Candidate Controlled Committee ❑ Primarily Formed Ballot Measure Q State Candidate Election Committee Committee Q Recall Q Controlled (Also -Complete Part 5) 0 Sponsored (Also Complete Part 6) ❑ General Purpose Committee 0 Sponsored ❑ Primarily Formed Candidate/ Q Small Contributor Committee Officeholder Committee Q Political Party/Central Committee (Also Complete Part 7) 3. Committee Information I.D NUMBER 1323307 :OMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTE Sandy Jack for Atascadero City Council 2010 STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE Atascadero Ca 93422 MAILING ADDRESS (IF DIFFERENT) NO AND STREET OR P.O BOX CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL. FAX / E-MAIL ADDRESS 4. Verification I have used all reasonable diligence in preparing and reviewing this statement and to the best of under penalty of perjury under the laws of the State of California that the foregoing is true and col Executed on 01/12/2010 Date Executed on 01/12/2010 Date Executed on Date By By COVER PAGE Date Stamp RECEIVED Date of election if applicable: JAN 2 8 2010 Page 1 of 4 (Month, Day Year) For Official Use Only CITY OF ATASCADEF O CITY CLERK'S OFFIC 2. Type of Statement: ❑ Preelection Statement ❑ Quarterly Statement ❑ Semi-annual Statement ❑ Special Odd -Year Report ® Termination Statement ❑ Supplemental Preelection (Also file a Form 410 Termination) Statement Attach Form 495 ❑ Amendment (Explain below) Treasurer(s) NAME OF TREASURER David P Bentz MAILING ADDRESS CITY STATE ZIP CODE AREA CODEIPHONE Atascadero Ca 93422 NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL. FAX / E-MAIL ADDRESS knowledge the information contained herein and in the attached schedules is true and complete. I certify By Signature of Controlling Officeholder, Candidate, State Measure Proponent Executed on BY Date Signature of Controlling Officeholder Candidate, Stale 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. COVERPAGE PART2 Recipient Committee CALIFORNIA Campaign Statement FORM ' • Cover Page — Part 2 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Sandy Jack OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) City Councilman Atascadero, Ca RESIDENTIAL/BUSINESS ADDRESS (NO AND STREET) CITY STATE ZIP Atascadero Ca 93422 Related Committees Not Included in this Statement: List any committees not included in this statement that are controlled by you or are primarily formed to receive contributions or make expenditures on behalf of your candidacy COMMITTEE NAME I LD NUMBER NAME OF TREASURERI GUN I KULLtU UUMMI I I tC! ❑ YES ❑ NO COMMITTEE ADDRESS STREETADDRESS (NO PO BOX) CITY STATE ZIP CODE AREA CODE/PHONE COMMITTEE NAME LD NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? ❑ YES ❑ NO COMMITTEE ADDRESS STREETADDRESS (NO PO BOX) Page 2 of 4 6. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE BALLOT NO OR LETTER JURISDICTION ❑ SUPPORT ❑ OPPOSE Identify the controlling officeholder, candidate, or state measure proponent, if any. NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY 7 Primarily Formed Candidate/Officeholder Committee List names of officeholder(s) or candidates) for which this committee is primarily formed. NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE 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 Summary Page Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period from 01/01/2010 SUMMARY PAGE SEE INSTRUCTIONS ON REVERSE $ 00 $ amounts in Column A to the through 01/12/2010 page 3 of 4 NAME OF FILER 00 Add Lines 6 + 7 $ 00 $ 00 I.D. NUMBER Sandy Jack for Atascadero City Council 2010 Schedule F Line 3 period amounts. If this is the first report being filed 1323307 Schedule C, Line 3 Column Column B Calendar Year Summary for Candidates Contributions Received any) TOTALTHIS PERIOD CALENDAR YEAR g Primary Running in Both the State Prima and (FROMATTACHEO SCHEDULES) TOTALTO DATE General Elections 1 Monetary Contributions Schedule A, Line 3 $ 00 $ 00 1/1 through 6/30 7/1 to Date <6000 00> 00 2. Loans Received Schedule B, Line 3 <6000 00> 00 20 Contributions 3. SUBTOTAL CASH CONTRIBUTIONS Add Lines 1 + 2 $ $ Received $ $ 00 00 4 Nonmonetary Contributions Schedule C, Line 3 21 Expenditures 5 TOTAL CONTRIBUTIONS RECEIVED Add Lines 3+4 $ <600000> $ 00 Made $ $ Expenditures Made 6. Payments Made 7 Loans Made 8. SUBTOTAL CASH PAYMENTS 9 Accrued Expenses (Unpaid Bills) 10 Nonmonetary Adjustment 11 TOTAL EXPENDITURES MADE Schedule E, Line 4 $ 00 $ amounts in Column A to the 00 00 Schedule H, Line 3 from Column B of your last 00 Add Lines 6 + 7 $ 00 $ 00 figures that should be 00 Schedule F Line 3 period amounts. If this is the first report being filed 00 Schedule C, Line 3 carry over the amounts Add Lines 8 + 9 + 10 $ 00 $ Current Cash Statement 12. Beginning Cash Balance Previous Summary Page, Line 16 $ 13. Cash Receipts Column A, Line 3 above 14 Miscellaneous Increases to Cash Schedule 1, Line 4 15. Cash Payments Column A, Line 8 above 16 ENDING CASH BALANCE Add Lines 12 + 13 + 14, then subtract Line 15 $ if this is a termination statement, Line 16 must be zero. 17 LOAN GUARANTEES RECEIVED Schedule A Part 2 $ Cash Equivalents and Outstanding Debts 18 Cash Equivalents See instructions on reverse $ 19 Outstanding Debts Add Line 2 +Line 9 in Column B above $ Wi, 11 11 11 11 Expenditure Limit Summary for State Candidates 22. Cumulative Expenditures Made* (if Subject to Voluntary Expenditure Limit) Date of Election Total to Date (mm/dd/yy) *Amounts in this section may be different from amounts reported in Column B. FPPC Form 460 (January/06) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/276-3772) To calculate Column B, add <6000 00> amounts in Column A to the 00 corresponding amounts from Column B of your last 00 report. Some amounts in Column A may be negative 00 figures that should be subtracted from previous period amounts. If this is the first report being filed 00 for this calendar year only carry over the amounts from Lines 2, 7 and 9 (if any) Expenditure Limit Summary for State Candidates 22. Cumulative Expenditures Made* (if Subject to Voluntary Expenditure Limit) Date of Election Total to Date (mm/dd/yy) *Amounts in this section may be different from amounts reported in Column B. FPPC Form 460 (January/06) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/276-3772) SCHEDULEB PART1 IYRU Ur Fllllll III IIIn. Schedule B — Part 1 Amounts may be rounded Statement covers period CALIFORNIA Loans Received to whole dollars. 01/01/2010 FORM from 01/12/2010 4 4 through Page of SEE INSTRUCTIONS ON REVERSE NAME OF FILER I.D. NUMBER Sandy Jack for Atascadero City Council 2010 1323307 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUALENTER , a OUTSTANDING (b) AMOUNT lal AMOUNT PAID (d) OUTSTANDING (e) INTEREST (f) ORIGINAL (g) CUMULATIVE OF LENDER OCCUPATION AND EMPLOYER (IF SELF-EMPLOYED, ENTER BALANCE BEGINNING THIS RECEIVED THIS OR FORGIVEN BALANCEAT CLOSE OF THIS PAID THIS AMOUNT OF CONTRIBUTIONS (IF COMMITTEE, ALSO ENTER I.D. NUMBER) NAME OF BUSINESS) PERIOD PERIOD THIS PERIOD' PERIOD PERIOD LOAN TO DATE i] PAID CALENDAR YEAR Sandy Jack Retired $ 600000 $ 00 0 600000 8250 San Diego Rd % $ $ ❑ FORGIVEN Atascadero, Ca 93422 RATE PERELECTION** $ 600000 $ 00 Demand $ 00 12/23/09 $ $ DATE DUE DATE INCURRED t❑ IND i6 COM ❑ OTH ❑ PTY ❑ SCC ❑ PAID CALENDAR YEAR ❑ FORGIVEN RATE PER ELECTION"* $ $ s s s DATE DUE DATE INCURRED t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ PAID CALENDAR YEAR PER ELECTION - FORGIVEN RATE DATE DUE DATE INCURRED t[3 IND ❑ COM ❑ OTH ❑ PTY ❑ SCC SUBTOTALS $ 00$ 600000 $ 00 $ 00 Schedule B Summary 1 Loans received this period (Total Column (b) plus unitemized loans of less than $100 ) 2. Loans paid or forgiven this period (Total Column (c) plus loans under $100 paid or forgiven ) (Include loans paid by a third party that are also itemized on Schedule A.) 3. Net change this period. (Subtract Line 2 from Line 1 ) 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. $ NET $ 00 600000 <6000 00> (May be a negative number) Schedule E, Line 3) tContributor Codes IND—Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g business entity) PTY — Political Parry SCC — Small Contributor Committee FPPC Form 460 (January/05) FPPC Toll -Free Helpline. 866/ASK-FPPC (866/2763772)