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Home My WebLink AboutJan Marx - Form 460 - Termination - 12-17-2012Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200 - 84216.5) SEE INSTRUCTIONS ON REVERSE Type or print in ink. Statement covers period from 10/1/2012 through 12/31/2012 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 ❑ General Purpose Committee (Also Complete Part 6) Q Sponsored ❑ Primarily Formed Candidate/ Q Small Contributor Committee Officeholder Committee Q Political Party /Central Committee (Also Complete Part 7) 3. Committee Information I I.D. NUMBER 1347247 COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) Jan Marx for Mayor 2012 STREET ADDRESS (NO P.O. BOX) 265 Albert Drive CITY STATE ZIP CODE AREA CODE /PHONE San Luis Obispo CA 93405 805 541 -2716 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 Stamp DECEIVED Date of election if applicable age 1 of � '0 (Month, Day, Year) DEC 17 X012 For Official Use Only 11/6/2012 SLO CITY CL 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) Treasurer(s) NAME OF TREASURER Gregory Ty Griffin MAILING ADDRESS 2075 Hutton CITY STATE ZIP CODE AREA CODE /PHONE San Luis Obispo CA 93401 805 543 -2679 NAME OF ASSISTANT TREASURER, IF ANY Jan Marx MAILING ADDRESS 265 Albert Drive CITY STATE ZIP CODE AREA CODE /PHONE San Luis Obispo OPTIONAL: FAX / E -MAIL ADDRESS CA 93405 805 541 -2716 jan @janmarx.com 4. Verification 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 corlji jj ,-7, „ ) _ ,1 Executed on . t L�r �/ 1 By - �'•E Signalurea €Tress AssutanlTraasvrer Executed on r / By Dais Sig - o!Pwimiling Otficeho€der.Can"le,state Was= Propmentor Responsible 0€fcero€sponsor. Executed on By Date Signature of Controlling Offmholde, Candidate, State Measure Proponent Executed on By Date Signature of Controlling Officeholder, Candidate, State Measure Proponent FPPC Form 460 (January/OS) FPPC Toll -Free Helpline: 866 1ASK -FPPC (866/275 -3772) State of California Recipient Committee Type or print in ink. COVERPAGE -PART2 Campaign Statement CALIFORNIA Cover Page — Part 2 FORM 460 6. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE Jan Marx OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) Mayor, San Luis Obispo RESIDENTIAUBUSI NESS ADDRESS (NO. AND STREET) CITY STATE ZIP 265 Albert Drive San Luis Obispo CA 93405 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 ID 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) CITY STATE ZIP CODE AREA CODE /PHONE I' Page 7/ of 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 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 Attach continuation sheets if necessary FPPC Form 460 (January/OS) FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772) State of California Campaign Disclosure Statement Type or print in ink. SUMMARYPAGE Amounts may be rounded Statement covers period Summary Page to whole dollars. CALIFORNIA A t from 10/21/2012 - 12/31/2012 3 SEE INSTRUCTIONS ON REVERSE through Page of NAME OF FILER I ID NUMBER Jan Marx for Mayor 2012 Ill 1347247 Contributions Received 1. Monetary Contributions ............ ............................... Schedule A, Line 3 $ 2. Loans Received ...................................... ....... ....... .. Schedule e, Line 3 SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1 +2 $ 4. Nonmonetary Contributions ..... ............................... Schedule C, Line 3 5. TOTAL CONTRIBUTIONS RECEIVED ................ ........... Add Lines 3 +4 $ Column A TOTALTHIS PERIOD (FROM ATTACHED SCHEDULES) 2,350 0 2,350 I Column B CALENDAR YEAR TOTALTO DATE $ 17,391 3,000 $ 20,391 800 2,350 $ 21,191 Expenditures Made 6. Payments Made ........................ ............................... Schedule E, Line 4 (� Q $ " u 7. Loans Made .................... ........................... . . .. .... . . . ... Schedule H, Line 3 d O 0 8. SUBTOTAL CASH PAYMENTS .... ............ _..--- . ........... Add Lines 6 +7 q $ l 4 9. Accrued Expenses (Unpaid Bills) . ------------- ......... ........ Schedule F Line 10. Nonmonetary Adjustment ........... ............................... Schedule C, Line 3 11. TOTAL EXPENDITURES MADE ... ....... ...................... Add Lines 8 +9 +10 $ Current Cash Statement Beginning Cash Balance ....................... Previous Summary Page, Line 16 $ 5,629 I s. Cash Receipts .................... ............................... Column A, Line 3 above 2,350 14. Miscellaneous Increases to Cash ........................... Schedule 1, Line 4 0 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 8 above $ $ 19129 0 $ 0- $ 2 It 25 ` 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). 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 Received $ $ 21. Expenditures Made $ $ 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) I // $ $ 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 (866/275 -3772) Schedule A Type or print in ink. Monetary Contributions Received Amounts may rounded to whole dollars. lars. SEE INSTRUCTIONS ON REVERSE Statement covers period from 10/21/2012 through 12/31/2012 SCHEDULE A Page 4 of NAMt wa- rILtK I D NUMBER Jan Marx for Mayor 2012 1347247 DATE FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVETO DATE PER ELECTION RECEIVED (IF COMMITTEE, ALSO ENTER I D NUMBER) CODE* OCCUPATION AND EMPLOYER RECEIVED THIS (IF SELF - EMPLOYED, ENTER NAME PERIOD CALENDAR YEAR (JAN. 1 -DEC 31) TO DATE (IF REQUIRED) OF BUSINESS) ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND see attached continuation sheet " " ❑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. 1,480 (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.) ....... ........... I— $ TOTAL $ 870 2,350 '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 1ASK -FPPC (866/275 -3772) Schedule A (Continuation Sheet) Statement covers period California Form 460 Monetary Contributions Received from 10/21/12 Page Z� of -to Name of filer: Jan Marx for Mayor 2012 through 12/31/12 I.D. Number: 1347247 Date Name and address Code Occupation & Employer $Period $YTD $Election 10/27 Marilyn Farmer 1350 Marsh St. , SLO, CA 93401 IND Architect, Habitat Studio 100 100 100 10/26 Julie Frankel 655 Oakrid e Dr., SLO, CA 93406 IND Artist, Self 100 100 100 10/26 Richard Frankel 655 Oakrid e Dr., SLO, CA 93406 IND Retired 100 100 100. 10/31 Linda Inchausti 1218 Sawleft Ct., SLO, CA 93401 IND Executive Director, Cal Poly 100 100 100 Jeffrey Aranguena for 12/3 721 Johnson Ave., #77, SLO, CA City Council, FPPC COM 100 100 100 93401 #1347665 11/2 Sandra Marshall- 1612 Lima Dr. SLO, CA 93405 lEminger IND Publisher, Self 100 100 100 , 10/311 Marla Peluso 557 Stonerid a Dr., SLO, CA 93401 IND Retired 100 100 100 10/31 Holly Naylor 1199 Laural, SLO, CA 93401 IND Teacher, San Luis Coastal Unified 20 120 120 School District 11/1 Milton Carrigan 2250 King Ct, #7, SLO, CA 93401 IND Retired 50 125 125 11/6 Donald Berry 3057 S. Higuera, #147, SLO, CA IND Retired 80 130 1301 93401 11/7 Michael Heyl 1867 Fixlini St., SLO, CA 93401 IND Teacher, Gover Unified School 30 130 130 District David Baldwin for Cuesta 12/13 College Trustee, FPPC 979 -E Osos St., SLO, CA 93401 COM 100 150 150 #1348103 10/21 John S atafore 753 Pacific St., SLO, CA 93401 IND lAttorney, Self 50 150 150 10/29 Eugene Spruill 370 Islay St., SLO, CA 93401 IND Hand man, Self 50 150 150 12/13 John Ashbaugh 193 Los Cerros Dr., SLO, CA 93406 IND City Councilman, City of SLO 100 200 200 10/27 Robert Shanbrom 364 Montrose Dr., SLO, CA 93405 IND Retired 200 200 200 1222 San Carlos Dr., SLO, CA 10/21 Stephen Weinstein IND Retired 100 200 200 93401 Subtotal this period 1,480 SCHFDUIFR - PART 1 scneauie b — vart i Amounts may be rounded Statement covers period Loans Received to whole dollars. 10/1/2012 • 1 from 12/31/2012 SEE INSTRUCTIONS ON REVERSE through page of NAME OF FILER I.D. NUMBER Jan Marx for Mayor 2012 1347247 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER OUTSTANDING BALANCE (b) AMOUNT (c) AMOUNT PAID (d) OUTSTANDING (e) INTEREST (f) ORIGINAL jg} CUMULATIVE OF LENDER (IF COMMITTEE, ALSO ENTERI D NUMBER) (IFSELF- EMPLOYED, ENTER BEGIAL BEGINNING THIS RECEIVED THIS OR FORGIVEN BALANCEAT CLOSE OF THIS PAID THIS AMOUNTOF CONTRIBUTIONS NAMEOFBUSINESS) PERI D PERIOD THIS PERIOD` PE RI PERIOD LOAN TO DATE Jan Marx Mayor, City of San Luis ETPAID 9 __" CALENDARYEAR 265 Albert Drive Obispo 990 Palm Street, $ $ O c) 0 San Luis Obispo San Luis Obispo CA [- FORGIVEN / RATE PER ELECTION- CA 93405 93401 $ 3,000.00 $ 0 Q Z% to IND ❑ COM ❑ OTH ❑ PTY ❑ SCC $ DATE DUE D TEIN URRED ❑ PAID CALENDARYEAR $ $ % $ $ ❑ FORGIVEN PER ELECTION"* RATE t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC $ $ $ S DATE INCURRED $ DATEDUE ❑ PAID CALENDAR YEAR $ $ % $ $ ❑ FORGIVEN PERELECTION*" RATE t❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC 5 $ $ $ DATE INCURRED $ DATE DUE SUBTOTALS $ $ $ $ Schedule B Summary 1. Loans received this period ................... ............................... (Total Column (b) plus unitemized loans of less than $100.) 2. Loans paid or forgiven this period ............................... ............................... (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.) ........... ............................... Enter the net here and on the Summary Page, Column A, Line 2. *Amounts forgiven or paid by another party also must be reported on Schedule A. ** If required. $ 3 '0 p Q I .... NET $ —� CDC? (May be a negative nurpber) (En(er(e) on 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 (8661275 -3772) Schedule E Payments Made SEE INSTRUCTIONS ON REVERSE NAME OF FILER Jan Marx for Mayor 2012 Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period from 10/1/2012 through 12/31/2012 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. Page / of I.D. NUMBER 1347247 1'J 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 FTID fundraising events POL polling and survey research TRS staff /spouse travel, lodging, and meals ,0 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 VVEB information technology costs (intemet, e-mail) NAME AND ADDRESS OF PAYEE (IF COMMITTEE, ALSO ENTER I D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNTPAID PRP ( #1026) 2224 Beebee POS 2019.08 San Luis Obispo CA 93401 Tribune Newspaper ( #1027) 3825 South Hlguera LIT 568.70 San Luis Obispo CA 93401 PRP ( #1028) 2224 Beebee POS 72.25 San Luis Obispo CA 93401 * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 16,60 Schedule E Summary 1. Itemized payments made this period. Include all Schedule E subtotals. $ 4 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).) ................................................ ............................... $ q 4. Total payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.) _... TOTAL, $ U y 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. Statement covers period from 10/1/2012 through 12/31/2012 SCHEDULE E Page O of t NAME OF FILER I.D. NUMBER Jan Marx for Mayor 2012 1347247 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. 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 PEF 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 RdD fundraising events POL polling and survey research TRS staff /spouse travel, lodging, and meals ,JD 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 (intemet, e-mail) NAME AND ADDRESS OF PAYEE (IFCOMMITEE, ALSO ENTER I D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNTPAID Peter Steynberg Gallery ( #1029) 1515 Monterey FND 200.00 San Luis Obispo CA 93401 Bank of America VISA ( #1030) PO Box 982235 LIT 2040.17 El Paso Texas 79998 -2235 Big Sky Restaurant 1121 Broad Street FND 100.00 San Luis Obispo CA 93401 " Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 2- 3+ 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.) ............................. TOTAL,$ FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772) Schedule E CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID Journal Plus Magazine ( #1032) SCHEDULE E (CONT.) (Continuation Sheet) Type or print in ink. Amounts may be rounded �� Osos Street Statement covers period CALIFORNIA ' Payments Made 650.00 to whole dollars. * from 10/1/2012 • PPS ( #1033) 12/31/2012 h through SEE INSTRUCTIONS ON REVERSE CNS 500.00 Page of NAME OF FILER I.D. NUMBER Jan Marx for Mayor 2012 697.76 1347247 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CMP campaign paraphernalia /misc. MBR member communications RAID 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 BID independent expenditure supporting /opposing others (explain)* POS postage, delivery and messenger services TSF transfer between committees of the same candidate /sponsor _EG 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 Journal Plus Magazine ( #1032) �� Osos Street PRT 650.00 San Luis Obispo CA 93401 PPS ( #1033) PO Box 1254 San Luis Obispo CA 93406 CNS 500.00 Bank of America (VISA) ( #1034) PO Box 982235 LIT 697.76 El Paso Texas 79998 -2235 ' Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $_ Li S FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 1ASK -FPPC (866/275 -3772) St^Hr:ni 11 F H Schedule H Type or print in ink. Statement covers period Loans Made to Others* Amounts may rounded 10/21/12 _ • to whole dollars. o from 12/31/12 SEE INSTRUCTIONS ON REVERSE through page _H__ of NAME OF FILER I.D. NUMBER Jan Marx for Mayor 1347247 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (a) OUTSTANDING (b) AMOUNT (c) REPAYMENT OR (d� OUTSTA DING (e) INTEREST M ORIGINAL (g) CUMULATIVE OF RECIPIENT (IF COMMITTEE, ALSO ENTER I.D. NUMBER) (IF SELF - EMPLOYED, ENTER BALANCE BEGINNING THIS LOANED THIS FORGIVENESS BALANCEAT CLOSE OF THIS RECEIVED AMOUNT OF LOANS NAME OF BUSINESS) PERIOD PERIOD THIS PERIOD' PERIOD LOAN TO DATE Jan Marx for Mayor 2012 ❑ PAID CALENDAR YEAR PO Box 1445 $ 974 $ 0 0 3000 $ 3000 % $ ❑ FORGIVEN PER ELECTION- San Luis Obispo,CA 93406 RATE $ 3000.00 $ 0 $ 2026 12/31/12 0 9/28112 $ 3000 $ DATE DUE DATE INCURRED E] PAID CALENDAR YEAR $ $ % $ $ FORGIVEN PER ELECTION"` RATE $ $ S $ $ DATE DUE DATE INCURRED "Loans that are contributions to another candidate or committee must also be summarized on Schedule D. Loans forgiven must also be reported on Schedule E. SUBTOTALS $ $ $ $ Schedule H Summary 1. Loans made this period .................................... ............................... (Total Column (b) plus unitemized loans of less than $100.) 2. Payments received on loans ............................. ............................... (Total Column (c) plus unitemized payments of less than $100.) 3. Net change this period. (Subtract Line 2 from Line 1.) .................... (Enter the net here and on the Summary Page, Column A, Line 7.) (enter (e) on Schedule I, Line 3) $ o —if Required .... ... I .............. $ 3000 ........ NET $ -3000 (May be a negative number) FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772)