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HomeMy WebLinkAboutTom Fischer - Form 410 AmendmentStatement of Organization Recipient Committee Statement Type ❑ Initial [21 Amendment Not yet qualified ❑ or List I.D. number: s 1366034 —/ —./ —/—/— Date qualified as committee Date qualified as committee Of apphc.ble) 1. Committee Information NAME OF COMMITTEE Tom Fischer for City Council 2016 ❑ Termination — See Part 5 List I.D. number: a Date of Termination STP,ELT ADDRESS (NO PO. BOX) 745 Dawn Way CITY STATE ZIPCODE AREA CODE /PHONE Gilroy CA 95020 (408)847 -4716 MAILING ADDRESS (IF DIFFER( NT) FAX / EMAIL ADDRESS tom4ciilrovO- outlook.com COUNTY OF DOMICILE. IURISDICIION WHERE COMMITTEE I$ ACTIVE Santa Clara Gilroy, CA Attach additional information on appropriately labeled continuation sheets. Ew. `� Date Stamp 4. 'a lr�lf ® AND FILE 'Al till office of the Secretary of Sh of Et1n Sfpte of califomia JAN 2 2 2015 Official Use Only\ 141 C RE FEB IVED FEB � 3115 mlFsom11r 2. Treasurer and Other Principal Officers NAME OF TREASURER Marie P Blankley �� STITH I ADDRESSINO P.O. ROX) 2290 Coral Bell Ct CITY STATE ZIP CODE AREA CODE /PHONE Gilroy CA 95020 (408)842 -4544 NAME OF ASSISTANT TREASURER, IF ANY Tom Fischer STREET ADDRESS(NOP.O BOX) 745 Dawn Way CITY STATE ZIP CODE AREA CODE /PHONE Gilroy CA 95020 (408)847 -4716 NAME OF PRINCIPAL OltICER(S) STREET ADDRESS (NO PO. BOX) CITY STATE ZIP CODE ARE A ( 0 [It /PHOW 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 and r the laws of the State of California that the e Vis tru a correct. Executed on Q By D fE CANDIDATE, OR STATE MEASURE PROPONENT Executed on LIME By OR STATE MEASURE Executed on By DATE SIGNATURE OF CONTROLLING OF F ICE HDI01 R. c. ANDIDATE, OR STAlt ME AsuRE PROPONENT FPPC Form 410 (Dec /2012) FPPC Advice: advice@fppc.ca.gov (866/275 -3772) www,fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE NUMBER COMMITTEE NAME I U. Tom Fischer for City Council 2016 1366034 • All committees must list the financial institution where the campaign bank account is located. NAME Of FINANCIAL INSTITUTION Pinnacle Bank AREA COD[ /PHONE (408)848 -7210 RANK ACCOUNT NUMBEK ZIP CODE ADDRESS 7597 Monterey St. Gilroy CA 95020 4. Type Of Committee Complete the applicable sections, W47 M17ni"'TaniGM • 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" • If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. ELECTIVE OFFICE SOUGHT OR HELD NAME OF CAN ICE.HO LDER /STATE MEASURE PROPONENT- (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION Tom Fischer I City Council Member 1 2016 Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S) NAME OR MEASURF(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(SI JURISDICTION. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) �+^ PARTY m Nonpartisan Q Nonpartisan"^ CHECK ONE FPPC Form 410 (Dec /2012) FPPC Advice: advice@fppc.ca.gov (866/275 -3772) www.fppc.ca.gov Statement of Organization Recipient Committee Statement Type ❑ Initial © Amendment Not yet qualified ❑ or List I.D. number: 111366034 Date qualified as committee Date qualified as committee )If appllcablc) 1. Committee Information NAME OF COMMITTEE Tom Fischer for City Council 2016 ❑ Termination — See Part 5 List I.D. number: r— t Date of Termination STREET ADDRESS (NO PO. BOX) - 745 Dawn Way CITY STATE ZIP CODE AREA CODE /PHONE Gilroy CA 95020 (408)847 -4716 MAILING ADDRESS IIF DIFFERENT) FAX/ EMAIL ADDRESS utlook.com COUNTY OF DOMICILE IURIS0ICTION WHERE COMMITTEE 15 ACOVI Santa Clara Gilroy, CA Attach additional information on appropriately labeled continuation sheets. 2. Treasurer and NAME OF TREASURER Marie P Blankley STREET ADDRESSINO PO, BOX) 2290 Coral Bell Ct CITY Date Stare OECEi ft JAN 1 9 2015 CITYCLERKS ofnC ` OIL Roy, CA Principal Officers For Official Use Only ITATT TIP LO DI. AREA CODE /PI ION Gilroy CA 95020 (408)842 -4544 NAME OF ASSISTANT TREASURER, IF ANY Tom Fischer STREET ADDRESS (NO P.O BOXI 745 Dawn Way Lily STATE ZIP CODE AREA CODE /PHONE Gilrov CA 05020 (408)847 -4716 NAME Of PRINCIPAL OFFICER(S) STREET ADDRESSINO P.O. BOX) CITY STATE ZIPCODE AREACODE /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 and r the laws of the State of California that the e i is tr a correct. Executed on / 0 By U TF CANDIDATE. OR STATE MEASURE PROPONENT Executed on DATE Executed on DATE By OR STATE By SIC NA7URE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATF MEASURE PROPONENT FPPC Form 410 (Dec /2012) FPPC Advice: advice@fppc.ca.gov (866/275 -3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Page 2 COMMITTEE NAME LD. NUMBER Tom Fischer for City Council 2016 11366034 • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION AREA CODE /PIIONE BANK ACCOUNT NUMBER Pinnacle Bank (408)848 -7210 ADDRESS CITY SIAIE ZIP CODE 7597 Monterey St. Gilroy CA 95020 4. Type of Committee Complete the applicable sections. A • 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" • 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 PARTY Tom Fischer City Council Member 2016 m Nonpartisan suEl ❑ Nonpartisan TIM ° ■ 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) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE s FPPC Form 410 (Dec /2012) �FPPC Advice: advice @fppc.ca.gov )866/275 -3772) www.fppc.ca.gov SUPPORT E OPPOSE suEl orl s FPPC Form 410 (Dec /2012) �FPPC Advice: advice @fppc.ca.gov )866/275 -3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEEINAME I.D. NUMBER Tom tFischer for City Council 201.6 1366034 ' r r Not formed to support or oppose specific candidates or measures in a single election. Check only one box: ❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee PROVIDE GRIEF DESCRIPTION OF ACTIVITY List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREET ADDRESS NO. AND STREET CITY STATE 21P CODE r I I r Date qualified r n o' can (date otficeholderT or: ro °onenticettit That alfof the.followin conditions have,been nTeE "; K 5 +Termination Requ�remen>rs I T� ! 6yslgning the verlficatioo the treasurer assistant treasure a d/i r d a p .p Y , g _ _ .. , _ „.,. , .y. -1 hv.. - �: .::. .... e - ..:.. .. - • 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 • 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. FPPGForm 410!(Oec/2612) FPPC Advice: advice @fppc.ca.gov (866/275 -3772) www.fppc.ca.gov Statement of Organization Recipient Committee Statement Type ❑ Initial Not yet qualified ❑ or // Date qualified as committee © Amendment List I.D. number: #1366034 -// Date qualified as committee (1f applicable) ❑ Termination — See Part 5 List I.D. number: a �� Date of Termination 1. Committee Information NAME Of COMMITTEE Tom Fischer for City Council 2016 STREET ADDRESS (NO P.O. BOX) 745 Dawn Way CITY STATE ZIP CODE AREA CODE /PHONE Gilroy CA 95020 (408)847 -4716 MAILING ADDRESS (IF DIFFERENT) FAX /E -MAIL ADDRESS COUNTY OF DOMICILE IU RISDICTION WHERE COMMITTEE IS ACTIVE Santa Clara Gilroy, CA Attach additional information on appropriately labeled continuation sheets. Date Stamp For Official Use Only 2. Treasurer and Other Principal Officers NAME OF TREASURER Marie P Blankley STREET ADDRESS (NO P.O. BOX) 2290 Coral Bell Ct. CITY STATE ZIP CODE AREA CODE /PHONE Gilroy CA 95020 (408)842 -4544 NAME OF ASSISTANT TREASURER, IF ANY Tom Fischer STREET ADDRESS (NO P.O. BOX) 745 Dawn Way CITY STATE ZIP CODE AREA CODE /PHONE Gilroy CA 95020 (408)847 -4716 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 of California that the reg i is correct. Executed on By CANDIDATE, OR STATE MEASURE PROPONENT Executed on DATE Executed on DATE By By OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (Dec /2012) FPPC Advice: advice @fppc.ca.gov (866/275 -3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME I I.D.,NUMBER Tom Fischer for City Council 2016 1366034 • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION AREACODE /PHONE "BANK ACCOUNT NUMBER Pinnacle Bank 1(408)848-7210 ADDRESS CITY STATE ZIPCODE 7597 Monterey St. Gilroy CA 95020 4' ;Type of� Cominlittee; Complete the :applicable sections ti .: 7 1 y - - =! • 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" • If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. ELECTIVE OFFICE SOUGHT OR HELD NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION iPARTY Tom Fischer City Council Member 2016 . ® Nonpartisan Sun ❑ Nonpartisan Primarily formed to support or oppose specific candidates or measures in�a single election. List below: CANDIDATES) NAME OR MEASURE(S) FULLTITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATES) OFFICE SOUGHT:OR HELD OR MEASURE(S)IJURISDICTION (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHFCK nNF FPPC Form 430 (Dec /2012) FPPC Advice: advice @fppc:ca.gov (866/275 -3772) www.fppcca.gov . r SUPPORT El OPPOSE El- Sun OPPOSE FPPC Form 430 (Dec /2012) FPPC Advice: advice @fppc:ca.gov (866/275 -3772) www.fppcca.gov . r Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE NAME Page 3 Tom Fischer for City Council 2016 NUMBER 4.T [1366034 Ype' of CamMitteel'`_ (Continued) Not formed to support or oppose p pp specific candidates or measures in a single election. Check only one box: ❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY :MAL List additional sponsors on an attachment. STREET CITY OR AFFILIATION OF SPONSOR ZIP CODE �............. Date qualified S. TerminaiioniR @C)UIre117ef1tS Bysigning ;theverification,,thefreasurer asslstanttreasure ►and /orcandldate offiteiiolder;or ro nentc ^.._,_. a ,._ 1---l— _ P M_ _ ertify:tha; albofithe following candltions have been, met; • 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 ihas no surplus funds; and • 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. FPPC Form 410 (Dec /2012) FPPC Advice: advice@fppc.ca.gov (866/275 -3772) www.fppc.ca.gov