HomeMy WebLinkAbout2018.09.27_Goldman_Jan_Form 410 AmendmentStatement of Organization
Recipient Committee
Statement Type ® Initial b• Amendment ❑ Termination — See Part 5
O Not yet qualified
or
• Date qualified as committee
09 19 2018
Date qualified as committee
Date of termination
Date Stamp
RECEIVED
City of Morro Bay
SEP272018
Administration
CALIFORNIA A 1 O
FORM '�F
For Official Use Only
1. Committee Information
I.D. Number 1410216
(if applicable)
2. Treasurer and Other Principal Officers
NAME OF COMMITTEE
Jan Goldman for City Council A 018
NAME OF TREASURER
John Erwin
STREET ADDRESS (NO P.O. BOX)
STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
CITY
Morro Bay
Morro Bay
CA 93442 70
STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
CA 93442 805,
MAILING ADDRESS (IF DIFFERENT)
E•MAI
COUN IS ACTIVE
Sal% ►,.,cAL5 O brsp � CrY a4 m a rr '8ay
Attach additional information on appropriately labeled continuation sheets.
STREET ADDRESS (NO P.O. BOX)
CITY
STATE ZIP CODE AREA CODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY
STATE ZIP CODE AREA CODE/PHONE
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and complete. I certify under
penalty of perjury under the laws of the State
Executed on 9/26/2018 By
DATE TREASURER
Executed on 9/26/2018 By
DATE
R STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410(February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
CALIFORNIA A 1 O
FORM 'F
Page 2
COMMITTEE NAME
Jan Goldman for City CouncilQOI 6
I.D. NUMBER
1410216
• All committees must list the financial institution where the campaign bank account Is located.
NAME OF FINANCIAL INSTITUTION
Wells Fargo Bank, N.A.
AREA CODE/PHONE BANK ACCOUNT NUMBER
805/771-8310
ADDRESS
Albertson's 730 Quintana Rd.
CITY
Morro Bay
STATE ZIP CODE
CA 93442
4. Type of Committee Complete the applicable sections.
Controlled Committee
• List the name of each controlling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled, also list the elective office sought or held, and
district number, if any, and the year of the election.
• List the political party with which each officeholder or candidate is affiliated or check "nonpartisan." Stating "No party preference" is acceptable.
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE)
YEAR OF
ELECTION
CHECK ONE
PARTY
Janith E Goldman
Morro Bay City Council
2018
Nonpartisan
Partisan
(IIst political party below)
1
Nonpartisan
Partisan
(list political party below)
Primarily Formed Committee
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT
OPPOSE
SUPPORT
OPPOSE
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Studc.nro f.n it is >> o' (ru a G Bi_:i -] g vfl
e ■ n ■
omnnritt-o
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Jan Goldman for City Council aUi g
IS MC=
40 '�1'�,�pe of Committee
(Continued)
General Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
OW Committee [-11 COUNTY Committee STATE Committee 0 Political Party/Central Committee
rdi
Page 3
I.D, NUMBER
1410216
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
To support Jan Goldman for City Council in the general elaction in Morro Ba, CA.
Sponsored Comrnittee
List additional sponsors on an attachment.
NAME OF SPONSOR
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS
NO, AND STREET
CITY
STATE
ZIP CODE
AREA CODE/PHONE
Small Contribute Co
/
Date qualified
5. Term°ohntlon Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent certify that all of the following conditions have been met:
o This committee has ceased to receive contributions and make expenditures;
• This committee does not anticipate receiving contributions or making expenditures in the future;
This committee has eliminated or has no intention or ability to discharge all debts, loans received, and other obligations;
This committee has no surplus funds; and
Q This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions.
�- There are restrictions on the disposition of surplus campaign funds held by elected officers who are leaving office and by defeated candidates. Refer to Government
Code Section 89519,
-- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511- 89518, and are
subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
Clem' Pp
ar
Print
Nib WINISIner
PPPC Form 6 (Fehi'&iar°0/2018)
FPPC Advice: advice@fppc.ca.gov (866/275M3772)
www.fppc,ca.gov