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Home My Public Portal AboutForm 460 (July 1 - Dec 31, 2011)F , , 7 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 July 1, 2011 through Dec. 31, 2011 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) O Sponsored (Also Complete Part 6) ❑ General Purpose Committee Q 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 1292533 COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) Committee to Elect Sam Pedroza, Claremont City Council 2011 STREET ADDRESS (NO P.O. BOX) 580 Cinderella Dr CITY STATE ZIP CODE AREA CODE/PHONE Claremont CA 91711 (909) 621-0615 MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL: FAX / E-MAIL ADDRESS COVER PAGE Date of election if applicable: FEB 0 12012 Page 1 of 7 (Month, Day, Year) CITY CLERK For Official Use Only 3/8/11 ITY OF CLARCRA®N 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) O Treasurer(s) NAME OF TREASURER Brian Teuber MAILING ADDRESS 553 Redlands Avee CITY STATE ZIP CODE AREA CODE/PHONE Claremont CA 91711 (909) 982-1568 NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS 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 knowledge the inform tained 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.. 4A 1/30/12 Executed on By Date ofTreasur r r Assistant Treasurer 1/3/12 �Pgnatur Executed on By Date SighakueRControllingOfficehdtler,Candidate, 4fate JAeasure Proponent orResponsible Officer ofSponsor Executed on By Date Signature of Controtling Officeholder, Candidate, State Measure Proponent Executed on By Date Signature of Controtling Officeholder, Candidate, State Measure Proponent FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) State of California Recipient Committee Campaign Statement Cover Page — Part 2 5. Officeholder or Candidate Controlled Committee Type or print in ink. NAME OF OFFICEHOLDER OR CANDIDATE Committee to Elect Sam Pedroza, Claremont City Council 2011 OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) City Council RESIDENTIAL/BUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP 207 HArvard Ave Claremont CA 91711 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.D. NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? ❑ YES ❑ NO COMMITTEE ADDRESS STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE COMMITTEE NAME I.D. NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? ❑ YES ❑ NO COMMITTEE ADDRESS STREETADDRESS (NO P.O. BOX) 6. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE COVER PAGE - PART 2 Page 2 of 7 BALLOT NO. OR LETTER JURISDICTION ❑ SUPPORT ❑ OPPOSE Identify the controlling officeholder, candidate, or state measure proponent, if any. O 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. 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 -1 i i —1— ur " 1a 1 Attach continuation sheets if necessary FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) State of California 3 Campaign Disclosure Statement Type or print in ink. Amounts may be rounded Summary Page to whole dollars. SEE INSTRUCTIONS ON REVERSE NAME OF FILER Committee to Elect Sam Pedroza, Claremont City Council 2011 Contributions Received TOColumnA TALTHIS PERI00 (FROMATTACHEO SCHEDULES) 1. Monetary Contributions ........................................... Schedule A, Line 3 $ 0 2. Loans Received...................................................... schedule e, Line 3 0 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1 + 2 $ 0 $ 4. Nonmonetary Contributions .................................... Schedule C, Line 3 0 5. TOTAL CONTRIBUTIONS RECEIVED......••••..•..............AddLines3+4 $ 0 $ Expenditures Made 6. Payments Made ....................................................... Schedule e, Line 4 $ 7. Loans Made............................................................. Schedule H, Line 3 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6 + 7 $ 9. Accrued Expenses (Unpaid Bills) ............................... Schedule F Line 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 3above 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 e, 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 $ 137.89 $ 0 137.89 $ 0 0 I Jr.O7 $ SUMMARYPAGE Statement covers period from July 1, 2011 through Dec. 31, 2011 page 3 of 7 I.D. NUMBER Column B CALENDARYEAR TOTALTODATE 10329.00 0 0 0 10329.00 10466.89 0 10466.89 0 365.00 10831.89 137.89 To calculate Column B, add 0 amounts in Column A to the corresponding amounts from Column B of your last 0 137.89 report. Some amounts in Column A may be negative 0 figures that should be subtracted from previous period amounts. If this is the first report being filed 0 for this calendar year, only carry over the amounts from Lines 2, 7, and 9 (if 0 any). 0 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 O Received $ $ 21. Expenditures Made $ $ Expenditure Limit Summary for State Candidates 22. Cumulative Expenditures Made* (N 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/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) O I Schedule A Monetary Contributions Received Type or print in ink. SCHEDULE A Amounts may be rounded Statement covers period to whole dollars. from July 1, 2011 Schedule A Summary 1. Amount received this period — itemized monetary contributions. (Include all Schedule A subtotals.)........................................................................................................ $ 2. Amount received this period — unitemized monetary 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 $ I I x "Contributor 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) Dec. 31, 2011 4 7 SEE INSTRUCTIONS ON REVERSE through Page of NAME OF FILER I.D. NUMBER Committee to Elect Sam Pedroza, Claremont City Council 2011 1292533 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 ENTERI.D.NUMBER) CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. 1 - DEC. 31) (IF REQUIRED) OF BUSINESS) ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑IND ❑ COM ❑ OTH ❑ PTY [:]SCC SUBTOTAL$ Schedule A Summary 1. Amount received this period — itemized monetary contributions. (Include all Schedule A subtotals.)........................................................................................................ $ 2. Amount received this period — unitemized monetary 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 $ I I x "Contributor 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) Type or print in ink. Schedule B — Part 1 Amounts may be rounded Loans Received to whole dollars. SEE INSTRUCTIONS ON REVERSE Statement covers period from July 1, 2011 through Dec. 31, 2011 NAME OF FILER Committee to Elect Sam Pedroza, Claremont City Council 2011 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL, ENTEROUTSTANDING AMOUNTOF AMOUNT (c) AMOUNT PAID OUTSTANDING OF LENDER OCCUPATION AND EMPLOYER (IF SELF-EMPLOYED, ENTER BALANCE BEGINNING THIS RECEIVED THIS OR FORGIVEN* BALANCEAT CLOSE OF THIS (IF COMMITTEE, ALSO ENTER I.D. NUMBER) NAME OF BUSINESS) P RIOD PERIOD THIS PERIOD PROD $ DATE INCURRED ❑ PAID CALENDARYEAR RATE PER ELECTION ❑ FORGIVEN DATE INCURRED t❑ IND$ ❑COM ❑ OTH ❑PTY F1 SCC CALENDARYEAR $ $ RATE PER ELECTION ** $ DATE DUE $ DATE INCURRED ❑ PAID ❑ FORGIVEN DATE DUE t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ PAID $ $ ❑ FORGIVEN $ $ $ DATE DUE t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC SUBTOTALS $ $ $ 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) NET $ 0 ................................................................ 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. SCHEDULE B -PART 1 Page 5 of 7 I.D. NUMBER 1292533 INTEREST ORIGINAL CUMULATIVE PAID THIS AMOUNTOF CONTRIBUTIONS PERIOD LOAN TO DATE CALENDARYEAR RATE PER ELECTION- O $ $ DATE INCURRED CALENDARYEAR RATE PER ELECTION DATE INCURRED CALENDARYEAR RATE PER ELECTION ** $ $ DATE INCURRED (tnter(e)an Schedule E, Line 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) Schedule C Type or print in ink. Amounts may be rounded SCHEDULE C Nonmonetary Contributions Received to whole dollars. Statement covers periodSam WENAM ' from July 1, 2011 SEE INSTRUCTIONS ON REVERSE through Dec. 31, 2011 Page 6 of 7 NAME OF FILER I.D. NUMBER Committee to Elect Sam Pedroza, Claremont City Council 2011 1292533 DATE FULL NAME, STREET ADDRESS AND CONTRIBUTOR IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER DESCRIPTION OF AMOUNT/ FAIR MARKET CUMULATIVE TO DATE PER ELECTION RECEIVED ZIP CODE OF CONTRIBUTOR (IF COMMITTEE, ALSO ENTER I.D. NUMBER) CODE * (IF SELF-EMPLOYED, ENTER GOODS OR SERVICES VALUE CALENDAR YEAR TO DATE (IF REQUIRED) NAME OF BUSINESS) (JAN 1 - DEC 31) ❑ IND ❑ COM ❑ OTH ❑ PTY \ ❑ SCC []IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑SCC Attach additional information on appropriately labeled continuation sheets. SUBTOTAL $ Schedule C Summary 1. Amount received this period — itemized nonmonetary contributions. (Include all Schedule C subtotals.)..................................................................................................................... $ 2. Amount received this period — unitemized nonmonetary contributions of less than $100 .................................... $ 3. Total nonmonetary contributions received this period. (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Lines 4 and 10.) ...................... TOTAL $ C I (• *Contributor 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) Schedule E Payments Made SEE INSTRUCTIONS ON REVERSE Type or print in ink. Amounts may be rounded to whole dollars. NAME OF FILER Committee to Elect Sam Pedroza, Claremont City Council 2011 Statement covers period from July 1, 2011 through Dec. 31, 2011 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. SCHEDULE E Page 7 of 7 I.D. NUMBER 1292533 CMP campaign paraphemalia/misc. MBR member communications RAD radio airtime and production costs CNS campaign consultants MTG meetings and appearances RFD returned contributions CT8 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 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 PAYEE (IF COMMITTEE, ALSO ENTER I.D. NUMBER) City of Claremont 207 Harvard Ave. Claremont, CA 91711 CODE OR DESCRIPTION OF PAYMENT CVC contribution for Helmet Program AMOUNT PAID 137.89 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 137.89 Schedule E Summary 1. Itemized payments made this period. Include all Schedule E subtotals. ............... $ 137.89 2. Unitemized payments made this period of under $100........................................................................................... $ 0 3. Total interest paid this period on loans. Enter amount from Schedule B, Part 1, Column e 0 4. Total payments made this period. Add Lines 1, 2, and 3. Enter here and on the Summa Page, Column A, Line 6. 137.89 p Y p l Summary 9 ) ............................. TOTAL $ FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)