HomeMy WebLinkAboutDICKERSON SEMIANN98(2) fficeholder, Candidate, Type of ...t i. i.k.
and Controlled Committee
Campaign Statement - Long Form
(Government Code Sections 84200-84216.5)
SEE INSTRUCTIONS ON REVERSE
Check one of the following boxes to indicate the type of statement being filed: [] Pro-election Statement
[] Supplemental Pro-election Statement (Attach a completed Form 495 to this statement.)
Statejnt i
onT ve period
from
through
Date of election if applkable:
(Month, Day, Year)
Date Stamp
COVER PAGE - LONG FORM
,,, ~ - 7
For official use only
CODE AREA CODE/DAYTIME PHONE
CffY STATE
COMMITTEE ADDRESS (NO. AND STREET) COMMITTEE NAME i I.O. NUMIER
CITY STATE ZIP CODE AREA CODE~AYTIME PHONE NAME Of TREASURER CONTR(XLED COMM~'I'EE?
NAME OF T~~ ~ ~k,l~~a~ COMMnTEE ADDRESS (NO. AND STRI~ET)
PERMANENT ADDRESS Of TREASURER (NO. AND STREET)
(NO. AND STREET)
STATE ZP CODE AREA CODE/DAYTIME
STATE ZiP CODE AREA CODE/DAYTIME
Attach Iddttionel information on appropriate/), led continuation sheets.
I have used ell reasonkble, iligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the c
DAntE CITY AND STATE / By
... ,o
reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the informat' rein and in the attached schedules is true and
DATE
Executed on At By
DATE CITy AND STATE SIGNATURE O~ CANDIDATE/OFFIC/H0tDER
Executed on At By
DATE CITY AND STATE SIGNATURE Of CANDIDATE/OFRCEHOLDER
FOR INFORMATION REOUIRID TO BE PROVIDED TO YOU PURSUANT TO TH~ INFORMATION PRACTICES ACT OF 1977, SEE INFORMATION MANUAl, ON CAMPAIGN DISCLOSURE PROVISIONS ~OF THE POLITICAL REFORM ACT
State of California Fair Political Practices Commission
OffiCE 5 IDA HELD (INCLUDE LOCATION AND DISTRICT NUMIER IF APPtlCAILE)
NAME Of TREASURER
COMMITTEE ADDRESS
I 0 · m n .,~ ois . amen
:fficehold e, a . ~-o~'~,~lot Included in this 5 :atement:
Included in this Statement
c~m~ees ~t i~1~ In thb c~ol~a/~ nate~nt ~t are c~frdl~ by y~
committees of which you have know/edge that are pHmarUy formed to receive contributions
Or to make expenditures on behalf of your cand/dacy.
COMMITTEE NAME ~ I.D. NUMIER
CONTROLLED COMMITTEE?
] YEs I"! NO
Campaign Disclosure Statement
Summary Page
SEE INSTRUCTIONS ON REVERSE
NAMI CONTROLLED COMMITTEE
Contributions Received /
1. Monetary Contributions ............................... Schedule A, Une
2. LOans Received ......................................... schedule a, Line
3. SUBTOTALCASHCONTRIBUTIONS ...................... Add Unes ; ,2
4. Non-monetary Contri butions ......................... Schedule C Line
5. SUBTOTAL CONTRIBUTIONSi(Exdude Enforeable Protnbes) AddUnes3 .~
6. Enforceable Promises
(Exclude Loan Guararrtees, Une 18 below) ................... Schedule D, Une
7, TOTAL CONTRIBUTIONS RECEIVED ..................... AddUnesS ·
Expenditures Made
8. Cash Payments (Other than Loans Made) ............
9, LOans Made .............................................
10. SUBTOTAL CASH PAYMENTS ............................
11. Accrued Expenses (Unpaid Bills) ........................
12. TOTAL EXPENDITURES MADE .........................
Current Cash Statement
Schedule E, Une 5 S
schedule H, Une 7
AddLines8 ~ 9 S
Schedule F, Une 5
AddLines 10. II S
13. Beginning Cash Balance .................. Previous Summary Page, une ; 7 S
14, Cash Receipts ......................................ColumnA, Line3ebove
15. Miscellaneous Increases to Cash ........................Schedule I, Line 4
16. Cash Payments ....................................ColumnA, Line lOebova
17. ENDING CASH BALANCE ..... AddLines 13, ;4 .; IS, then subtract Une ;6 S
If this IS m termination Statement, Line; 7 must be zerO.
18. LOAN GUARANTEES RECEIVED .............. Schedule a, Pan;, Column(b)
Cash Equivalents and Outstanding Debts
19. Cash Equivalents ................................ ~ee instruction on twverse
20. Outstanding Debts ................. AddLine 2 , Line l; inColumnCabeve
Type or prim In ink. S U M MARY PAGE
Amounts may be rounded Statem~ve, r~;
to whok ddbrs. : :' ' ·
from
I.D, NUMBER
Column A Column B* Column C
TOTAL THIS ITRIOD TOTAL PREVIOUS I~RIOD TOTAL TO DATE
(FROM ATTACI~D S4~EDULES) GEE NOTE IELOW) (ADD COLUMNS A · I)
s _ s 2'7./723." _ s '?-~,)
C .':"') 2-7,/'
s icc>~ s 7Z3." _ s 'Z.I, Z3,"
.--- , .-- _ ,
b T . s ~..~.."' s I I TT".
ENDING CASH IALANCE SHOULD
NOT BE A NEGATIVE AMOUNT
* From previous Statement Summary Page, Column C. However, if
this is the firSt reDort filed for the calendar year, Column e should be
blank except for Loam Received (Line 2), Enforceable Promises (Line
6), Loans Made (Line 9), and Accrued Expenses (Line 11).
Summary for Candidates in Both June and
November Elections
s ?(/723.'
1tl through 6/30 7/I to Date
S ~ 21. ontrib tions ,~ ~
. .4-
Sched u le A Type or print in ink, SCHEDULE A
FULL NAME AND ADDRESS OF CONTRIBUTOR OCCUPATION AND EMPLOYER AMOUNT CUMULATIVE TO DATE
DATE (~F COMMrrrEE, IN ADDITION TO (0MMITrEE°S NAME AND ADDRESS, ENTER ~.O. NUMBER (IF SELF-EMPLOYED, ENTER RECEIVE D TH IS CALENDAR YEAR
RECEIVE D De, le MO I.O. NUMBER HAS IEEN ASSIGNED, ENTER TREASURERS NAME AND ADDRESS) NAME O~ BUSIneSS) PERIOD (JAN. 1 - DEC. 3 1 )
CUMULATIVE TO DATE
OTHER
(IF APPLICABLE)
SUBTOTAL
Monetary Contributions Summary
1. Amount received this period -- contributions of $100 or more.
(Include all Schedule A subtotals.) ....................................................................................................$
2. Amount received this period -- contributions of less than $100.
(Do not itemize.) .......................................................................................................................$
3. Total monetary contributions received this period.
(Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1 .) ....................................... TOTAL $
Schedule B -- Part I
Loans Received
Type 4x print in ink.
Amounts may be rounded
to whole dollars,
SEE INSTRUCTIONS ON REVERSE
DATE
RECEIVED
LENDER OR GUARANTOR'S FULL NAME AND ADDRESS
(if COMMITTEE, ENTER I~ULL NAME, ADDI~S$ ANO I.D. NUMI4ER. if NO I,D.
NUMIER HAS BEEN ASSIGNtO, ENTER THE TREA$URER'$ NAME AND ADDRESS)
LENDER/GUARANTOR'S
OCCUPATION AND EMFtOYER (if SELF-
EMPLOYED. ENTER BUSINESS NAME )
I'i Lender rl Guarantor *
from
DU~ DATE/
INTERE$T RATE
DUE DATE
INTEREST RATE
DUE DATE
INTEREST RATE
i"1 Lender I'l Guifrantor ·
DUE DATE
INTEREST RATE
LENDER INFORMATION
AMOUNT
O~ LOAN
I'1 Lender [] G ua ra ntOr *
· See important instructions on reverse. SUBTOTAL
Loans Received - Part I Summary
1. Loans of15100 or more received this period. (Include all Loans Received -Part l(a)subtotals.) .......... 15
2. Loans under 15100 received this period. (Do not itemize.) ........................................... $
). Total loans received this period. (Add Lines 1 and 2.) ....................................... TOTAL 15
Loans Received - Part II Summary
4. Loans of 15100 or more repaid, forgiven, or paid by a third party this period. (Include all Part II (c)
subtotals. If forgiven or paid by a third party, also itemize the transaction on Schedule A.) ..............
5. Loans under 15100 repaid, forgiven, or paid by a third party. (Do no itemize.) If forgiven or
paid by a third party° include this amount on Schedule A Summary, Line 2 ............................
6. Total loans repaid, forgiven, or paid by a third party this period.
(Add Lines 4 + 5.) ....................................................................... TOTAL $ (
7. Net change this period. (Subtract Line 6 from Line 3.)
Enter the net here and on the Summary Page, Column A, Line 2 ................................ NET $
CUMULATNE
TO DATE
CALENDAR YEAR
OTH[R
$
CAL[NDAR YEAR
$
OTHER
$
CALENDAR YEAR
$
OTHER
$
SCHEDULE B - Part I
,.. '~ - 7
I.D. NUMBER
GUARANTOR INFORMATION
AMOUNT CUMULATIVE
GUARANTEED TO DATE
CALENDAR YEAR
S
OTHER
CALENDAR YEAR
$
OTHER
CALENDAR YeAR
s
OTHER
Une ';S oe~y.
ldk :")
Mly be e negative number
Schedule B -- Part II Typeor print in ink. SCHEDULE B- Part II
Amounts may be rounded
DATE OF
REPAYMENT DATE OF
OR ORIGINAL LOAN FULL NAME OF LENDER
FORGIVENESS
INTEREST AMOUNT REPAID OR ·
RATE FORGIVEN ON PRINCIPAL OUTSTANDING
(IF CHANGED) (EXCLUDE PAYMENT OF iNTEREST) PRINCIPAL
(c)
Attach additional information on appropriately labeled continuation sheets. SUBTOTAL $
*IMPORTANT: If any part of a loan is forgiven or repaid by a third party, also itemize the transaction on Schedule A,
including the name and address of the person forgiving the loan or the third party making the payment, and the amount
forgiven or paid.
TOTAL INTEREST
PAID THIS PERIOD
INTEREST
PAID
(d)
s
Enter the amount in column (a') in the
summary Section of S<hedule E, Line 3. Do
not carry this total to the summary section of
Schedule B,
Schedule B -- Part III
Annual Report of Outstanding Loans Received
SEE INSTRUCTIONS ON REVERSE
NAME OF OFFICEHOLDER OR CANDIDATE AND CONTROLLED 4:0 MITTE
ORIGINAL DATE OF LOAN
It
It
Type or print in ink.
Amounts may be rounded
to whole dollars.
Statement q[verrw~kd~,iod'
,,, 1' Z
through I Z 15( 4~ ~
AMOUNT OF ORIGINAL LOAN
UNPAID PRINCIPAL
t
~7'=/o.--
Attach additional information on appropriately labeled continuation sheets.
TOTAL ~ $
NOTE: this total should be
the Mine emount el entered
on the Summary Page,
Column C, Line 2.
SCHEDULE B - Part III
Page 6 of_ /
I.D. NUMBER
8'3tr~l
UNPAID INTEREST
Sch ed u leE Type or print in ink. SCH E DU LEE
(Other Than Loans) Made -
If one of the following codes accurately describes the expenditure, ou may enter the code and leave the "Description of Payment' co|umn blank. Refer to the
back of Schedule E-Continuation Sheet for detailed explanations otY;ach category.
'c" - MONETARY AND IN-KIND (NON-MONETARY) *B' -
CONTRIBUTIONS TO OTHER CANDIDATES 'N* -
AND COMMITTEES 'O' -
'1" - INDEPENDENT EXPENDITURES 'S" -
°L'- LITERATURE "F"-
BROADCAST ADVERTISING
NEWSPAPER AND PERIODICAL ADVERTISING
OUTSIDE ADVERTISING
SURVEYS, SIGNATURE GATHERING, DOOR-TO-DOOR SOLICITATIONS
FUNDRAISING EVENTS
NAME AND ADDRESS OF PAYEE, CREDITOR, OR RECIPIENT OF CONTRIBUTION
(If CONIMITrE[, IN ADDITION TO COMMRTEE'5 NAME AND ADDRES$, ENTER I.O, NUMIER OR, If NO I.O.
NUMIER HAS IEEN ASSIGNED, ENTER TREASURER'S NAME AND ADORES5)
*G" - GENERAL OPERATIONS AND OVERHEAD
'T" - TRAVEL, ACCOMMODATIONS AND MEALS
(MUST BE DESCRIBED)
'P'- PROFESSIONAL MANAGEMENT AND CONSULTiNG
SERVICES
Im rtant: Contributions and expenditures made out of campaign funds to or on behalf of other
°n~*ce; SUBTOTAL $
holders, candidates, committees, or be~ot measures must also be entered on the Allocation Page, Part I.
IMPORTANT: DO NOT ITEMIZE THE PAYMENT OF ACCRUED EXPENSES ON SCHEDULE E,
REPORT ONLY THE LUMP SUM OF SUCH PAYMENTS ON LINE 4 OF THE SUMMARY SECTION BELOW,
CODE ~~ DESCRIPTION OF PAtMENT AMOUNT PAID
Payments and Contributions Made Summary '
1. Payments made this period of $100 or more. (Include all Schedule E subtotals.) ...................................................... $
2. Payments made this period of under $100. (Do not itemize.)
....................................................................... $
3. Total interest paid this period on outstanding loans. (Enter amount from Schedule B, Part II, Column (d).) .............................. $
4. Total accrued expenses paid this period. (Do not itemize. Enter amount from Schedule F, Line 4.) ..................................... $
5. Total payments made this period. (Add Lines 1, 2, 3, and 4. Enter here and on the Summary Page, Column A, Line 8) ........... TOTAL $