The URL can be used to link to this page

Home My WebLink AboutForms 460 12-31-2011 Sandy Jack for Atascadero City Council 2010Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200-84216.5) Type or print in ink. Statement covers period from 07/01/2011 SEE INSTRUCTIONS ON REVERSE Preelection Statement I through 12/31/2011 1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4. ® Officeholder, Candidate Controlled Committee ❑ Primarily Formed Ballot Measure 0 State Candidate Election Committee Committee 0 Recall 0 Controlled (Alan Complete Parte) 0 Sponsored (Also Complete Pert 6) ❑ General Purpose Committee 0 Sponsored ❑ Primarily Formed Candidate! 0 Small Contributor Committee Officeholder Committee 0 Political Party/Central Committee (Also Complete Parr 7) 3. Committee InformationI I.D. NUMBER 132834 COMMITTEE NAME (Oft CANDIDATE'S NAME IF NO COMMITTEE) Sandy Jack for Atascadero City Council STREET ADDRESS (NO P.O. BOX) 8250 San Diego Road ZIP CODE AREA CODE/PHONE Atascadero CA 93422 805-610-9287 MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR PO, BOX CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL'. FAX / E-MAIL ADDRESS Date of election if applicable: (Month, Day, Year) Date Stamp RECEIVED 11/2/2010 CITY OF ATAS CITY CLERK'S 2. Type of Statement: ❑ Preelection Statement ® Semi-annual Statement ❑ Termination Statement (Also file a Form 410 Termination) ❑ Amendment (Explain below) Treasurer(s) Sandy Jack i Am COVER PAGE of ❑ Quarterly Statement ❑ Special Odd -Year Report ❑ Supplemental Preelection Statement - Attach Form 495 MAILING ADDRESS 8250 San Diego Road CITY STATE ZIP CODE AREA CODE/PHONE Atascadero CA 93422 805-610-9287 NAME OF ASSISTANT TREASURER, IF ANY MAILING CITY STATE ZIP CODE AREA CODE,PHONE OPTIONAL: FAX / E-MAIL ADDRESS 4. Verification I have used all reasonable diligence in preparing and reviewing this statement and to the best of my k /ledge t e information cont eRE, and in the attached schedules is true and complete. I certify under penalty of perjury under the laws ofthe State of California that the foregoing is true and correct J�j Executed on b ��% / / �'^ By V/ oats Signal easurer slant Treas r Executed on By Det ign re ofControlling0 bolder, Candidate, rata Measure PioponeM or Responsible OfficerofSpons<s Executed on By Dale Sgnature of Controlling Officeholder Caud date, State Measure Proponent Executed on By Deis Signatureo(Cootrolling Officeholtler, CarMidate, Stale Measure Proponent FPPC Form 460 (January/05) FPPC Tollfree Helpline: 866/ASK-FPPC (866/275-3772) State of California Campaign Disclosure Statement Type or print in ink. SUMMARY PAGE Summar!/ Page Amounts may be rounded to whole dollars. ®-NIA 460 Statement covers period from 07/01/2011 FORM through 12/31/2011 page Z of J SEE INSTRUCTIONS ON REVERSE NAME OF FILER I.D. NUMBER Sandy Jack for Atascadero City Council -141 f 132834 Contributions Received Column A Column B Calendar Year Summary for Candidates TOTALTHISPERM (PROMATTACHED SCHEDULES) CALENDAR YEAR TOTALTODATE Running In Both the State Primaand 9 - Primary General Elections 1. Monetary Contributions ..._ ................._..........._...... Schedule A, Lines $ _____ 0 $ _ 253.57 2 _ Loans Received .................................................... Schedule e B, Line 3 ___ _19700.00 1/1 through 6/30 711 to Date 3. SUBTOTALCASH CONTRIBUTIONS ......................... Add Linesl+z 5000.00 $_ 19953.- $ 57 20. Contributions _ --- Received $ ._ $ _ 4. Nonmonetary Contributions ................................ Schedule 0 --- 0 --- - 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED ...........................Add Lines s+4 $ _. 5000.00 $ -___ 19953.57 ___._. Made $ $_ Expenditures Made Expenditure Limit Summary for State 6. Payments Made ... .................... schedule E, Line 4 $ 0 $ 14564.73 Candidates 7. Loans Made............................................................. ScheduieH,Lme3 0 0 _ 0 14564.73 22. Cumulative Expenditures Made* 8. SUBTOTAL CASH PAYMENTS ................ .................... Add lines 6+7 $ _ $ (if Subjeet to Voluntary Expenditure Limit) 9. Accrued Expenses (Unpaid Bills)��Schedule F, Line --.----0 0- Date of Election Total to Date 10. Nonmonetary Adjustment ................................... __... schedule C, Line _ 0 0 (mm/dd/yy) 11. TOTAL EXPENDITURES MADE .......... ...................... Add Lines 8+9+10 $ _. 0 $ _ 14564.73_ - $ Current Cash StatementJ----- 12. Beginning Cash Balance ....................... Previous Summary Page, Line 16 $ 3$$.22 To calculate Column B, add 13. Cash Receipts .......... ........................................ Column A, Line 3above __. 5000.00 amounts in Column A to the 0 corresponding amounts *Amounts in this section maybe different from amounts 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 8 above 0 report. Some amounts in Column A may be negative 16. ENDING CASH BALANCE .......... Add Lines 12 + 13 + 14, then subtract Line 15 $ 5388.22 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, Pan 2 $ for this calendar year, only carry over the amounts from Lines 2, 7, and 9 (if Cash Equivalents and Outstanding Debts any). 18. Cash Equivalents.. ............ _........................ See instructions on reverse $ 19. Outstanding Debts ._...................... Add Line 2 +Line 9 in Column B above $ _.._- FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866tASK-FPPC (8661275-3772) SCHEDULEB-PART1 Schedule B — Part 1 Amounts may be rounded Statement covers period fto Loans Received to whole dollars. 07/01/2011 CALIFORNIA from FORM 12/31/2011 SEE INSTRUCTIONS ON REVERSE through Page =3 of NAME OF FILER I.D. NUMBER Sandy Jack for Atascadero City Council 2 cP!c 132834 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL, ENTER a OUTSTANDING (b) AMOUNTOUTSTANDING (c) AMOUNT PAID Ph (e) INTEREST (f ORIGINAL I9) CUMULATIVE OF LENDER OCCUPATION AND EMPLOYER OFSAMEMPBOYED,ENTER BALANCE BEGINNING THIS RECEIVED THIS OR FORGIVEN BALANCEAT CLOSE OF THIS PAID THIS AMOUNTOF CONTRIBUTIONS (IE COMMITTEE, ALSO ENTER i D. NUMBER) NAME of Business) P R D PERIOD_ THIS PERIOD* PERIOD PERIOD LOAN TO DATE William S. Jack Retired D PAID CALENDARYEAR 8250 San Diego Road $ 0 5000.00 0 , 5000.00 $ _ 2011 D FORGIVEN Atascadero, CA 93422 RATE PER ELECTION*' $ 4000.00 $ 0 $ 0 Demand 0 7/1_6/10 19700.00 T[Z IND COM D OTH D PTY [j SCC D DATE URRED INC DATE DUE D PAID CALENDARYEAR $ 0 $ 0 $ % I $ _. . FORGIVEN PER ELECTION ** RATE I $ 0 $ 0 $ 0 $ $ DATE DUE tD IND D COM D OTH❑ PTY ❑ SCC DATE INCURRED D PAID CALENDARYEAR $ 0 & 0 $ % $ D FORGIVEN I PER ELECTION RATE $ $ 0 $ 0 5 0 $ DATE DUE tEl IND D COM D OTH D PTY D SCC DATE INCURRED SUBTOTALS $ 0 $ 0 $ 5000.00 $ 0�^ 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. $ (entet(e)on Schedule E, Une3) 5000.00 C 0 NET$ (M., 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 FPPC Form 460 (Januatylos) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Type or print in ink. SCHEDULEB-PART1 Statement covers period Schedule B— Part 1 Amounts may be rounded Loans Received to whole dollars. 07/01/2011 CALIFORNIA � • t from _.____. ®. 12/31/2011 SEE INSTRUCTIONS ON REVERSE through Page —_ of NAME OF FILER ID.NUMBER Sandy Jack for Atascadero City Council 2-41 s ' 132834 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL, ENTER a OUTSTANDING Ib) AMOUNT I.) gMOUNT PAID (d) OUTSTANDING (e) INTEREST O ORIGINAL ( (g) CUMULATIVE OF LENDER OCCUPATION AND EMPLOYER (IF SELF EMPLOYED, ENTER BALANCE BEGINNING THIS- 1 RECEIVED THIS OR FORGIVEN BALANCEAT CLOSE OF THIS I PAID THIS AMOUNTOF CONTRIBUTIONS prcoMMTTEE,ALSO ENTERED. NUMBER) NAMEOFBUSINESS) PERI D PERIOD THIS PERIOD` PE D PERIOD LOAN TO DATE William S. Jack Retired Ej PAID CALENDARYEAR 8250 San Diego Road 0 4000.00 0 , $ 4000.00 $ 2010 FORGIVEN PER ELECTION - Atascadero, CA 93422 RATE 4000.00 0 0 Demand 0 7/16/10 s 12000.00 t[vi IND ❑ COM ❑ OTH ❑ PTY D SCC DATE INCURRED DATE DUE ❑PAIL) CALENDARYEAR William S. Jack Retired $ 0 $ 1600.00 0 1600.00 $ 2010 8250 San Diego Road , $ FORGIVEN PER ELECTION Atascadero, CA 93422 RATE 1600.00 0 $ 0 Demand $ 0 11/22/10 13600.00 $ DATE DUE DATE INCURRED tN4 IND ❑ COM ❑ OTH ❑ PTY ❑ SCC William S. Jack Retired ❑ PAID CALENDARYEAR 8250 San Diego Road $ 0L1060. 0 1100.00 $ 2010 E]FORGIVENRATE PER ELECTION'''*$1100.00 Atascadero, CA 93422 0 0$0 10/27/10 14700.00 tQ IND ❑COM ❑ OTH ❑ PTY El SCC $ DATE INCURRED SUBTOTALS $ 0 $ 0 $ 6700.00 $ 0 Schedule B Summary 1. Loans received this period................................................................................._................................ $ 0 (Total Column (b) plus unitemized loans of less than $100.) 2. Loans paid or forgiven this period......................................................................................................... $ 0 (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. 0 9 P ()..................._........_....................._......... NET $ Enter the net here and on the Summary Page, Column A, Line 2. (MayeeanegaLVe a,) 'Amounts forgiven or paid by another party also must be reported on Schedule A. '* If required. 3) tContributor Codes IND–Individual COM – Recipient Committee (other than PTY or SCC) OTH – Other (e.g., business entity) PTY–Political Party SCC – Small Contributor Committee FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) Y61CI•Bill •:8E7_T m .''1... r,,,,,......... Schedule B— Part 1 Amounts may be rounded Statement covers period Loans Received to whole dollars. 07/01/2011 • from ..... ®- '_ 12/31/2011 SEE INSTRUCTIONS ON REVERSE through Page �� of NAME OF FILER I.D. NUMBER Sandy Jack for Atascadero City Council ZoP I0 132834 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL, ENTER a OUTSTANDING b AMOUNT (d (N) OUTSTANDING AMOUNTPAID (e) INTEREST (f) ORIGINAL (g) I CUMULATIVE OF LENDER OCCUPATION AND EMPLOYER (IFSELF-EMPLOYEOENTER BALANCE BEGINNING THIS RECEIVED THIS BALANCEAT OR FORGIVEN CLOSE OF THIS PAID THIS AMOUNT OE CONTRIBUTIONS (IFCOMMITTEE ALSO ENTER L D. NUMBER) NAMEOFBUSINESS) P I PERIOD THIS PERIOD* I PERIOD PERIOD LOAN TO DATE William S. Jack Retired ❑ PAID CALENDARYEAR 8250 San Diego Road $ 0 $ 2500.00 0 % 2500.00 $ 2010 PER ELECTION*' Atascadero, CA 93422 FORGIVEN RATE 2500.00 $ 0 $ 0 Demand B 0 7/16/10 $ 25.00.00 }'PJ IND ❑COM ❑ OTH ElPTY El SCC $ DATE DUE DATE INCURRED William S. Jack Retired E] PAID CALENDARYEAR 0 2500.00 0 2500.00 $ 2010 8250 San Diego Road $ ._.__ $ % $ PERELECTION" Atascadero, CA 93422 E] FORGIVEN RATE $ 2500.00 $ 0 0 Demand $ 0 11/22/10 $ 5000.00 $ tZ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED William S. Jack Retired ❑ PAID CALENDARYEAR 8250 San Diego Road $ 0 3000.00 0 , $ 3000-0 $ 2010 PER ELECTION** Atascadero, CA 93422 ❑ FORGIVEN RATE $ 3000_00 $ 0 0 Demand $ 0 10/27/10 8000.00 $ $ DATE INCURRED tZ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE SUBTOTALS $ 0 $ 0 $ 8000.00 $ 0 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. E" L Q NET $ 0 (May be a nega[ve numbeo (Enter (e) on Schedule E, Dne 3) tContributor Codes IND—Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY—Political Party SCC — Small Contributor Committee FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)