Loading...
HomeMy Public PortalAboutForm 460 (Oct. 18 - Dec. 31, 2020)Recipient Committee Date Stamp COVER PAGE Campaign Statement �' • 1 Cover Page SEE INSTRUCTIONS ON REVERSE Statement covers period from 10/18/20 through 12/31/20 1. Type of Recipient Committee: All Committees — Complete Parts 1, 2, 3, and 4. © Officeholder, Candidate Controlled Committee ❑ Primarily Formed Ballot Measure O State Candidate Election Committee Committee O Recall O Controlled (Also Complete Part 5) O Sponsored (Also Complete Part 6) ❑ General Purpose Committee 0 Sponsored ❑ Primarily Formed Candidate/ O Small Contributor Committee Officeholder Committee O Political Party/Central Committee (Also Complete Part 7) 3. Committee Information I I.D. NUMBER COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) Committee to Elect Sal Medina STREET ADDRESS (NO P.O. BOX) 257 E Green St CITY STATE ZIP CODE AREA CODE/PHONE Claremont CA 91711 6268330170 MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX 3016 Knollwood Ave CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL: FAX/ E-MAIL ADDRESS 4. Verification Date of election if applicable: (Month, Day, Year) November 3, 2020 1 2. Type of Statement: so Preelection Statement YSemi-annual Statement ❑ Termination Statement (Also file a Form 410 Termination) ❑ Amendment (Explain below) Page t of For Official Use Only ❑ Quarterly Statement ❑ Special Odd -Year Report Treasurer(s) NAME OF TREASURER Lindsey Shiomi MAILING ADDRESS 3016 Knollwood Ave CITY STATE ZIP CODE AREA CODE/PHONE La Verne CA 91750 7145194085 NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE OPTIONAL: FAX/ E-MAIL ADDRESS 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 correct. Executed on 1/29/21 Date Executed on 1/29/21 Date Executed on Date Executed on Date By By By Signature of Controlling Officeholder, Candidate, State Measure Proponent By Signature of Controlling Officeholder, Candidate, State Measure Proponent FPPC Form 460 (Jan/2016)) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Recipient Committee Campaign Statement Cover Page — Part 2 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Sal Medina OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) Claremont City Council, District 5 RESIDENTIAL/BUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP 257 E Green St 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 AREACODE/PHONE 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 COVER PAGE - PART 2 Page - of 5 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 Listnames 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 Attach continuation sheets if necessary FPPC Form 460 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Campaign Disclosure Statement Amounts may be rounded Summary Page to whole dollars. Statement covers period from 10/18/20 SUMMARY PAGE Expenditures Made 6. Payments Made................................................................ Schedule E, Line 4 5 SEE INSTRUCTIONS ON REVERSE 7. Loans Made....................................................................... Schedule H, Line 3 0 through 12/31/20 Page of NAME OF FILER $ 10,129.23 9. Accrued Expenses (Unpaid Bills) .......................................... Schedule F Line 3 0 I.D. NUMBER COMMITTEE TO ELECT SAL MEDINA Schedule C, Line 3 0 0 11. TOTAL EXPENDITURES MADE....................................Add 1433397 Contributions Received $ 10,129.23 Column A TOTAL THIS PERIOD Column B Calendar Year Summary for Candidates (FROM ATTACHED SCHEDULES) CALENDAR YEAR TOTAL TO DATE Running in Both the State Primary and General Elections 1. Monetary Contributions................................................... Schedule A, Line 3 $ 400 $ 11,523 0 0 1/1 through 6/30 7/1 to Date 2. Loans Received................................................................ Schedule e, Line 3 400 11,523 20. ContributionsReceived 3. SUBTOTAL CASH CONTRIBUTIONS .............................. Add Lines 1 + 2 $ $ $ $ 4. Nonmonetary Contributions ............................................ Schedule C, Line 3 0 0 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED................................Add Lines 3+4 $ 400 $ 11,523 Made $ $ Expenditures Made 6. Payments Made................................................................ Schedule E, Line 4 $ 1095.95 $ 10,129.23 7. Loans Made....................................................................... Schedule H, Line 3 0 0 8. SUBTOTAL CASH PAYMENTS ....................................... Add Lines 6+7 $ 1095.95 $ 10,129.23 9. Accrued Expenses (Unpaid Bills) .......................................... Schedule F Line 3 0 0 10. Nonmonetary Adjustment......................................................... Schedule C, Line 3 0 0 11. TOTAL EXPENDITURES MADE....................................Add Lines 8+9+10 $ 1095.95 $ 10,129.23 Current Cash Statement 12. Beginning Cash Balance ............................ Previous Summary Page, Line 16 $ 2089.72 13. Cash Receipts........................................................... Column A, Line 3 above 400 14. Miscellaneous Increases to Cash .................................. Schedule /, Line 4 0 15. Cash Payments......................................................... Column A, Line a above 1095.95 16. ENDING CASH BALANCE ..................Add Lines 12 + 13 + 14, then subtract Line 15 $ 1393.77 If this is a termination statement, Line 16 must be zero. 17. LOAN GUARANTEES RECEIVED ................................ Schedule e, Parte $ 0 Cash Equivalents and Outstanding Debts 18. Cash Equivalents ................................................ See instructions on reverse $ 0 19. Outstanding Debts .............................. Add Line 2 + Line 9 in Column 8 above $ 0 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). 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 (Jan/2016)) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Schedule A Amounts may be rounded SCHEDULE A LO whole dollars. Monetary Contributions Received Statement covers period from 10/18/20 - 12/31/20 Page SEE INSTRUCTIONS ON REVERSE through _1— of NAME OF FILER I.D. NUMBER COMMITTEE TO ELECT SAL MEDINA 1433397 FULL NAME, STREET ADDRESS AND ZIP CODE OF IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION DATE CONTRIBUTOR RECEIVED CONTRIBUTOR CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE (IF COMMITTEE, ALSO ENTER I.D. NUMBER) (IF SELF-EMPLOYED, ENTER NAME PERIOD (JAN. 1 - DEC. 31) (IF REQUIRED) Z IND 10/25/20 James Keith El COM Tutor Supervisor, P 100 100 337 Marygrove Rd. ❑ OTH Claremont After School Claremont, CA 91711 ❑ PTY Program ❑ SCC m IND 10/25/20 Davidacks J El COM President, David Jacks (self 100 250 744 Via Santa Catarina ❑ OTH employed) Claremont, CA 91711 ❑ PTY ❑ SCC IND 12/27 David Jacks ❑ COM President, David Jacks (self 150 250 744 Via Santa Catarina ❑ OTH employed) Claremont, CA 91711 ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC SUBTOTAL $ 350 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 $100 3. Total monetary contributions received this period. (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1.)........ 350 .............$ — .............$ 50 TOTAL $ 400 *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 (Jan/2016)) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Schedule E Payments Made SEE INSTRUCTIONS ON REVERSE COMMITTEE TO ELECT SAL MEDINA Amounts may be rounded Statement covers period to whole dollars. from 10/18/20 through 12/31/20 I Page 0 of r CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. 1433397 CMP 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 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) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID FedEx CMP Printing 112 Harvard Ave, Claremont, CA 91711 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. Schedule E Summary 1. Itemized payments made this period. (Include all Schedule E subtotals.)................................................................................................ 2. Unitemized payments made this period of under $100............................................................................................................................. 3. Total interest paid this period on loans. (Enter amount from Schedule B, 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.) ........................... 413.76 SUBTOTAL $ 413.76 413.76 68219 .......... $ . ............ $ 0 TOTAL $ 1095.95 FPPC Form 460 (Jan/2016)) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov