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Home My Public Portal AboutForm 460 (Jan 1 - Jan 22, 2005) Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200-84216.5) COVER PAGE: Type or print in ink. Date Stamp CALIFORNIA 460 2001/02 FORM RECEIVED from 01/01/05 Date of election if applicable: (Month. Day, Year) JAN 2 7 2005 Page 1 of 7 Statement covers period SEE INSTRUCTIONS ON REVERSE through 01/22/05 03/08/05 CITY CLERK ';CT'f OF CLAREMONT For Official Use Only 1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4. [XI Officeholder, Candidate Controlled Committee 0 Ballot Measure Committee 0 State Candidate Election Committee 0 Primarily Formed 0 Recall 0 Controlled (Also Complete Part 5) 0 Sponsored (Also Complete Part 6) 2. Type of Statement: [XI 0 0 0 Preelection Statement Semi-annual Statement Termination Statement Amendment (Explain below) 0 Quarterly Statement 0 Special Odd-Year Report 0 Supplemental Preelection Statement - Attach Form 495 0 General Purpose Committee 0 Sponsored 0 Small Contributor Committee 0 Political Party/Central Committee 0 Primarily Formed Candidate! Officeholder Committee (Also Complete Part 7) 3 C .tt I f t. II.D. NUMBER . omml ee norma Ion 1273509 COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) Committee to Elect Sam Pedroza Treasurer(s) NAME OF TREASURER Brian Teuber MAILING ADDRESS 553 Redlands Avenue STREET ADDRESS (NO P.O. BOX) 580 Cinderella Drive CITY Claremont STATE CA ZIP CODE 91711 AREA CODE/PHONE 909-621-0615 CITY Claremont NAME OF ASSISTANT TREASURER, IF ANY STATE CA ZIP CODE 91711 AREA CODE/PHONE 909-482-1568 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 I E-MAIL ADDRESS 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 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 cor,ct. . '\ J\. - Executed on f /':"1./ ú 5 By ~.- , \ . Date --- ¡J Signat.ure I¡asurfr Assistant Treasurer Executed on i 1-z... (, I (J > By -1.'":\- .,- ~ ' """ S'M,"~ of Coo Ii" Offi_~. Ca~" S~'" M~fi""".' o.~ of Spoo~ Executed on Dale By Signature of Controlling Officeholder, Candidate, Slate Measure Proponent Executed on Dale By Signature of Controlling Officeholder, Candidate, State Measure Proponent FPPC Form 460 (June/01) FPPC Toll-Free Helpline: 866/ASK-FPPC State of California Type or print in ink. Recipient Comm ittee Campaign Statement Cover Page - Part 2 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Sam Pedroza OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) City of Claremont - City Council RESIDENTIAUBUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP 580 Cinderella Drive Claremont, CA 91711 Related Committees Not Included in this Statement: List any committees not included in this statement that are control/ed by you or are primarily formed to receive contributions or make expenditures on behalf of your candidacy. COMMITIEE NAME I.D. NUMBER NAME OF TREASURER CONTROLLED COMMITIEE? 0 YES 0 NO STREET ADDRESS (NO P.O. BOX) COMMITIEE ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE COMMITIEE NAME I.D. NUMBER NAME OF TREASURER CONTROLLED COMMITIEE? 0 YES 0 NO COMMITIEE ADDRESS STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE COVER PAGE - PART 2 CALIFORNIA 460 FORM Page 2 of 7 6. Ballot Measure Committee NAME OF BALLOT MEASURE BALLOT NO. OR LETIER JURISDICTION 0 SUPPORT 0 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 Committee List names of officeholder(s) or candidate(s) for which this committee is primarily formed. NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD 0 SUPPORT 0 OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD 0 SUPPORT 0 OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD 0 SUPPORT 0 OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD 0 SUPPORT 0 OPPOSE Attach continuation sheets if necessary FPPC Form 460 (JunelO1) FPPC Toll-Free Helpline: 866/ASK-FPPC State of California Campaign Disclosure Statement Summary Page SEE INSTRUCTIONS ON REVERSE NAME OF FILER Committee to Elect Sam Pedroza Contributions Received 1. Monetary Contributions. """""""""" ............ """"" Schedule A, Une 3 2. Loans Received ...................................................... Schedule 8, Une 3 3. SUBTOTAL CASH CONTRIBUTIONS """""""""""'" Add Lines 1 + 2 4. Nonmonetary Contributions .................................... Schedule C, Line 3 5. TOTAL CONTRIBUTIONS RECEIVED ........................... Add Lines 3 + 4 Expenditures Made 6. Payments Made ....................................................... Schedule E, Une 4 7. Loans Made ............................................................. Schedule H, Line 3 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6 + 7 9. Accrued Expenses (Unpaid Bills) ............................... Schedule F, Une 3 10. Nonmonetary Adjustment .......................................... Schedule C, Line 3 11. TOTAL EXPENDITURES MADE ................................Add Lines 8 + 9 + 10 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 I, Une 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 8, Part 2 Cash Equivalents and Outstanding Debts 18. Cash Equivalents .............................,.......... See instructions on reverse 19. Outstanding Debts ......................... Add Line 2 + Line 9 in Column 8 above Type or print in ink. Amounts may be rounded to whole dollars. Column A TOTAL THIS PERIOD (FROM ATTACHED SCHEDULES) $ 875.00 5000.00 5875.00 0.00 5875.00 $ $ $ 863.12 0.00 863.12 2951.11 0.00 3814.23 $ $ $ 0.00 5875.00 0.00 863.12 5011.88 $ $ 0.00 $ $ 0.00 7951.11 from through Column B CALENDAR YEAR TOTAl TO DATE $ 875.00 5000.00 5875.00 0.00 5875.00 $ $ $ 863. 12 0.00 863.12 2951.11 0.00 3814.23 $ $ To calculate Column B. add amounts in Column A to the corresponding amounts from Column B of your last report. Some amounts in Column A may be negative figures that should be subtracted from previous period amounts. If this is the first report being filed for this calendar year, only carry over the amounts from Lines 2. 7, and 9 (if any). SUMMARY PAGE Statement covers period CALIFORNIA 460 FORM 01/01/05 01/22/05 3 of 7 Page 1.0. NUMBER 1273509 Calendar Year Summary for Candidates Running in Both the State Primary and General Elections 1/1 through 6/30 7/1 to Date 20. Contributions Received $ 21. Expenditures Made $ $ $ 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) I I $ I / $ I I $ I I $ I I $ I I $ *Since January 1, 2001. Amounts in this section may be different from amounts reported in Column B. FPPC Form 460 (June/01) FPPC Toll-Free Helpline: 866/ASK-FPPC Schedule A Monetary Contributions Received Type or print in ink. Amounts may be rounded to whole dollars. SEE INSTRUCTIONS ON REVERSE NAME OF FILER Committee to Elect Sam Pedroza from Statement covers period 01/01/05 through 01/22/05 SCHEDULE A CALIFORNIA 4 6 0 FORM 4 of 7 Page 1.0. NUMBER 1273509 FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION DATE OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE (IF COMMITTEE, AlSO ENTER 10. NUMBER) RECEIVED CODE * (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. 1 - DEC. 31) (IF REQUIRED) OF BUSINESS) 01/15/05 Georgeann Andrus I8J IND College Professor 75.00 75.00 75.00 DCOM 231 W. 10th Street DOTH Claremont, CA 91711 DPTY Retired DsCC 01/19/05 Judy Wright /KJIND Writer 100.00 100.00 100.00 DCOM 472 W. 10th Street DOTH Claremont, CA 91711 DPTY Claremont Historic DsCC Resources 01/19/05 James Keith /KJIND General Manager 100.00 100.00 100.00 DCOM 337 Marygrove Road DOTH Claremont, CA 91711 DPTY Hon Company Dscc 01/20/05 Brian Teuber IKIND Accountant 250.00 250.00 250.00 DCOM 553 Redlands Avenue DOTH Claremont, CA 91711 DPTY San Gabriel Basin Water DsCC Quality Authority 01/21/05 Amy Mathieson /KJIND HR Manager 250.00 250.00 250.00 DCOM 1776 Bridgeport Avenue DOTH Claremont, CA 91711 DPTY Toys 'R Us DSCC SUBTOTAL $ Schedule A Summary 1. Amount received this period - contributions of $1 00 or more. (Include all Schedule A subtotals.) ........................................................................................................ $ 2. Amount received this period - unitemized contributions of less than $100............................................. $ 3. Total monetary contributions received this period. (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1.) ....................... TOTAL $ 775.00 100.00 875.00 775.00 ,. *Contributor Codes 'NO -Individual COM - Recipient Committee (other than PTY or SCC) OTH - Other PTY - Political Party SCC - Small Contributor Committee ~ FPPC Form 460 (June/01) FPPC Toll-Free Helpline: 866/ASK-FPPC Schedule B - Part 1 Loans Received SEE INSTRUCTIONS ON REVERSE NAME OF FILER Committee to Elect Sam Pedroza FULL NAME. STREET ADDRESS AND ZIP CODE OF LENDER (IF COMMITTEE. ALSO ENTER 1.0. NUMBER) IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (IF SELF-EMPLOYED, ENTER NAME OF BUSINESS) Sam Pedroza 580 Cinderella Drive Claremont, CA 91711 Environmental Planner County Sanitation Districts of Los Angeles County t IX! INO 0 COM 0 OTH 0 PTY 0 SCC Sam Pedroza 580 Cinderella Drive Claremont, CA 91711 Environmental Planner County Sanitation Districts of Los Angeles County tlXJ IND 0 COM 0 OTH 0 PTY 0 SCC to IND 0 COM 0 OTH 0 PTY 0 SCC % $ $ RATE PER ELECTION ** $ DATE INCURRED 0.00 Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period 01/01/05 from through 01/22/05 (d) (e) (a) (b) (e) OUTSTANDING INTEREST OUTSTANDING AMOUNT AMOUNT PAID BALANCE AT PAID THIS BALANCE RECEIVED THIS OR FORGIVEN CLOSE OF THIS PERIOD BEGINNING THIS PERIOD THIS PERIOD * PERIOD PERIOD 0 PAID 0 2500.00 % $ $ RATE 0 FORGIVEN 0.00 0.00 2500.00 $ $ $ DATE DUE $ 0 PAID 0 2500.00 % $ $ RATE 0 FORGIVEN 0.00 0.00 2500.00 $ $ $ $ DATE DUE 0 PAID $ 0 FORGIVEN $ $ $ $ $ DATE DUE SUBTOTALS $ 0.00 $ 5000.00 $ 5000.00 $ (Enter (e) on Schedule E, Line 3) Schedule B Summary 1. Loans received this period .................................................................................................................... $ (Total Column (b) plus unitemized loans 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.) ............................................................... NET $ Enter the net here and on the Summary Page, Column A, Line 2. [ t Contributor Codes IND -Individual COM - Recipient Committee (other than PTY or SCC) 5000.00 0.00 5000.00 (May be a negative number) OTH - Other SCC - Small Contributor committee] FPPC Form 460 (JuneI01) FPPC Toll-Free Helpline: 866/ASK-FPPC PTY - Political Party SCHEDULE B - PART 1 CALIFORNIA 4 6 0 FORM Page 5 of 7 1.0. NUMBER 1273509 (f) (g) ORIGINAL CUMULATIVE AMOUNT OF CONTRIBUTIONS LOAN TO DATE CALENDAR YEAR $ 2500.00 $ 2500.00 PER ELECTION** 01/07/05 2500.00 $ DATE INCURRED CALENDAR YEAR $ 2500.00 $ 5000.00 PER ELECTION ** 01/15/05 5000.00 $ DATE INCURRED CALENDAR YEAR ~ , * Amounts forgiven or paid by another party also must be reported on Schedule A. ** If required. '- Schedule E Payments Made Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period from 01/01/05 CALIFORNIA 4 6 0 FORM SCHEDULE E SEE INSTRUCTIONS ON REVERSE NAME OF FILER through 01/22/05 6 Page I.D. NUMBER of 7 Committee to Elect Sam Pedroza CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CfvP 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 ÆT petition circulating TEL tv. 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 NJ independenl expenditure supporting/opposing others (explain,. POS postage, delivery and messenger services TSF transfer between committees of Ihe same candidate/sponsor LEG legal defense PRO professional services (legal. accounting) VOT voter registration LIT campaign literature and mailings FlU print ads WEB information technology costs (internet. e-mail) 1273509 NAME AND ADDRESS OF PAYEE (IF COMMITTEE, AlSO ENTER /.D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID Whalen Bindery & Mailing Services 535 W. Allen Avenue No. 16 San Dimas, CA 91773 POS 721.22 Printing Works 681 Foothill Boulevard Pomona, CA 91767 LIT 139.90 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $ 861.12 Schedule E Summary 1. Payments made this period of $1 00 or more. (Include all Schedule E subtotals.) .............................................. """""""""""'" ---........................ $ 2. Unitemized payments made this period of under $100 """"""""""'" ........................................................ """""""""""'" """"""'" ................... $ 3. Total interest paid this period on ioans. (Enter amount from Schedule 8, Part 1, Column (e).)............................................................................... $ 4. Total payments made this period. (Add Lines 1,2. and 3. Enter here and on the Summary Page, Column A, Line 6.) ............................. TOTAL $ 861.12 2.00 0.00 863. 12 FPPC Form 460 (June/01) FPPC Toll-Free Helpline: 866/ASK-FPPC Schedule F Accrued Expenses (Unpaid Bills) Type or print in ink. Amounts may be rounded to whole dollars. SCHEDULE F from 01/01/05 01/22/05 CALIFORNIA 460 FORM Statement covers period SEE INSTRUCTIONS ON REVERSE NAME OF FILER through Page I.D. NUMBER Committee to Elect Sam Pedroza 1273509 7 of 7 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CtvP 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 ÆT petition circulating TEL tv. 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 PRT print ads WEB information technology costs (internet, e-mail) NAME AND ADDRESS OF CREDITOR (IF COMMITTEE, ALSO ENTER 1.0. NUMBER) (a) OUTSTANDING BALANCE BEGINNING OF THIS PERIOD (c) AMOUNT PAID THIS PERIOD (ALSO REPORT ON E) (b) AMOUNT INCURRED THIS PERIOD CODE OR DESCRIPTION OF PAYMENT Whalen Bindery & Mailing Services 535 W. Allen Avenue San Dimas, CA 91773 p~S 0.00 244.86 0.00 Typegallery 20461 East Valley Boulevard Suite A Walnut, CA 91789 LIT 0.00 2706.25 0.00 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTALS $ 2951.11 $ $ 0.00 $ Schedule F Summary 1. Total accrued expenses incurred this period. (Include all Schedule F, Column (b) subtotals for accrued expenses of $100 or more, plus total unitemized accrued expenses under $100.) ............................................ INCURRED TOTALS $ 2. Total accrued expenses paid this period. (Include all Schedule F, Column (c) subtotals for payments on accrued expenses of $100 or more, plus total unitemized payments on accrued expenses under $100.) ................................. PAID TOTALS $ 3. Net change this period. (Subtract Line 2 from Line 1. Enter the difference here and on the Summary Page, Column A, Line 9.) ................................................................................................................................................ NET $ (d) OUTSTANDING BALANCE AT CLOSE OF THIS PERIOD 244.86 2706.25 2951.11 2951.11 0.00 2951.11 FPPC Form 460 (June/O1) FPPC Toll-Free Helpline: 866/ASK-FPPC May be a negative number