Form 410 Initial 07/26/11tement of Organization
,,ipient Committee
ement Type ® Initial
Not yet qualified ❑ or
3,
26 / 11
Date qualified as committee
mmittee Information
AME OF COMMITTEE
,$haffer for Council 2012
TREET ADDRESS (NO P.O. BOX)
STATEMENT OF ORGANIZATION
Type or print in ink ���///
Date Stamp
❑ Amendment ❑Termination —See Part 5 °=
For Official Use Only
List I.D. number: List I.D. number:
J I
Date qualified as committee
(If applicable)
1042 N. El Camino Real, Suite B -262
ITY STATE ZIP CODE AREA CODE /PHONE
Encinitas CA 92024
(AILING ADDRESS (IF DIFFERENT)
Date of Termination
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Lisa Shaffer
STREET ADDRESS (NO P.O. BOX)
569 Kristen Court
CITY STATE ZIP CODE AREA CODE /PHONE
Encinitas CA 92024
NAME OF ASSISTANT TREASURER, IFANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
113TIONAL: FAX I E -MAIL ADDRESS
NAME OF PRINCIPAL OFFICER(S)
OUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE STREET ADDRESS (NO P.O. BOX)
San Diego
CITY STATE ZIP CODE AREA CODE /PHONE
ttach additional Information on appropriately labeled continuation sheets.
ferification
have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained erein is true and complete. I certify under penalty of
erjury under the laws of the State of California that the foregoing is true and correct.
.>~_C 1
.xecuted on .� % c�► � c� U � ( By
r rAiE - -- SIGNAT RE EASUR RORASSISTANTTREASURER
i
xecuted on L t k' ' By �LZ
DATE
_AIGI14ATURE OF CONTROLLING OFFICEVClkDER, CANDIDATE, OR STATE MEASURE PROPONENT
xecuted on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
xecuted on By
DATE SIGNATURE
FPPC Form 410 (April /2011)
FPPC Toll -Free Heipline: 8661ASK -FPPC (8661275 -3772)
tatement of Organization
recipient Committee
STRUCTIONS ON REVERSE
STATEMENT OF ORGANIZATION
)MMITTEE NAME I.D. NUMBER
. Type of Committee Complete the applicable sections.
• 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 "non- partisan."
• 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 PARTY
Lisa Shaffer
Encinitas City Council
2012
® Non - Partisan
❑ Non - Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER
Mission Federal Credit Union 800 - 500 -MFCU 002826377
ADDRESS CITY STATE ZIP CODE
PO Box 919023 San Diego CA 92191
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S)
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
FPPC Form 410 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)
tement of Organization
-.ipient Committee
ement Type ® initial
Not yet qualified ❑ or
71 26 t 11
Date qualified as committee
mmittee Information
AME OF COMMITTEE
.$haffer for Council 2012
TREET ADDRESS (NO P.O. BOX)
Type or print in ink
❑ Amendment
List I.D. number:
Date qualified as committee
(if applicable)
3 H D 2�s(e: � 2
❑ Termination — See Part 5
List I.D. number:
1042 N. El Camino Real, Suite B -262
ITY STATE ZIP CODE AREA CODE /PHONE
Encinitas CA 92024
(AILING ADDRESS (IF DIFFERENT)
1110TIONAL: FAX/ E -MAIL ADDRESS
THAN COUNTY OF DOMICILE
San Diego
ttach additional information on appropriately labeled continuation sheets,
Date of Termination
STATEMENT OF ORGANIZATION
Date
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Lisa Shaffer
STREET ADDRESS (NO P.O. BOX)
569 Kristen Court
CITY STATE ZIP CODE AREA CODE /PHONE
Encinitas CA 92024
NAME OF ASSISTANT TREASURER, IF ANY
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 AREACODE /PHONE
ferification
have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained
erjury under the laws of the State of California that the foregoing is true and correct.
xecuted on ..� r..{ -` ��. U ( By
SIGNAT 6tE REA
xecuted on �.� 1-ti+ I gY
DATE
IG ATURE OF CONTROLLING OFFICEH
xecuted on
DATE
xecuted on
DATE
is true and complete. I certify under penalty of
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (April /2011)
FPPC Toil -Free Helpiine: 866/ASK -FPPC (866/2754772)
tatement of Organization
recipient Committee
STRUCTIONS ON REVERSE
STATEMENT OF ORGANIZATION
)MMITTEE NAME II.D. NUMBER
. Type of Committee Complete the applicable sections.
LOARSWWASQ90M
• 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 "non- partisan."
• 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 PARTY
Lisa Shaffer
Encinitas City Council
2012
® Non - Partisan
❑ Non - Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREACODE /PHONE BANKACCOUNTNUMBER
Mission Federal Credit Union 800- 500 -MFCU 002826377
ADDRESS CITY STATE ZIP CODE
PO Box 919023
San Diego
CA 92191
• . . Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S)
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
FPPC Form 410 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)