Form 410 Initial 10/14 2015 N
ai
7 �Statement of Organization Date Stamp
Recipient Committee $
Statement Type �� ❑ Amendment ❑ Termination—see Part 5
YP Initial RECEIVED AND FILED For Official Use Only
Notyetquarified❑ or List I.D.number. List LD.number:
in 111 otrtce of the Secretary o(8igta
# # of the State of Cali(omfe
112015 /- _/_ / OCT,19 2015
Date qualified as committee Date qualified as committee Date of Termination
(If app0mbk)
,71111111111 1. 11,11111 111 1111,1111 � ,
ow N ago
NAMEOFCOMMITTEE NAME OF TREASURER
Tasha Boerner Horvath for Council 2016 Tasha Boerner Horvath
ZtP CODE AREA CODE/PHONE -
Encinitas CA 92024 (760)274-4905 Encinitas CA 92024 (760)274-4905
MAILING ADDRESS(IF DIFFERENT) NAME OF ASSISTANT TREASURER,IF ANY
FAX/E-MAIL ADDRESS STREET ADDRESS(NO P.O.BOX)
tasha4encinitas @gmail.com
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE CITY STATE ZIP CODE AREA CODE/PHONE
San Diego Encinitas
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS(NO P.O.BOX) i
Attach additional information on appropriately labeled continuation sheets.
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CITY STATE ZIP CODE AREACODE/PHONE
I have used all reasonable diligence in preparing this statement pAiAto the be of owledge the information contained herein is true and complete. I certify under
penalty of perjury under the laws of the State 0 li r is th th forego' s tr d correct.
Executed on 10/14/2015 B y
DATE SIGNATURE OF TREASU RER OR ASSISTANT TREASURER
Executed on By 0
DATE SIGNATURE OF CONTROLLING OOICEHOLDER,CANDIDATE,OR 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 i
FPPC Form 410(Dec/2012)
FPPC Advice:advice@fppc.ca.gov(8661275-3772)
www.fppc.ca.gov
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Statement of Organization CALIFORNIA
Recipient Committee FORM 410
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME LD.NUMBER
Tasha Boerner Horvath for Council 2016
• All committees must list the financial institution where the campaign bank account is located.
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NAME OF FINANCIALINSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
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Wells Fargo Bank (760)479-6600
ADDRESS CITY STATE ZIP CODE
687 S Coast Hwy 101 #151 Encinitas CA 92024
• 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 theyear of the election.
• List the political party with which each officeholder or candidate is affiliated or check"nonpartisan." j
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• If this committee acts jointly with another controlled committee,list the name and identification number of the other controlled committee.
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ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
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® Nonpartisan
Tasha Boerner Horvath Encinitas City Council 2016
❑Nonpartisan
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• Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S)NAME OR MEASURE(S)FULLTITLE(INCLUDE BALLOT NO.OR LETTER) CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION
YINCLUDE DISTRICT NO.,CITY OR 000NTY,AS APPLICABLE) CHECK ONE
SUPPORT OPPOSE
El
So UM
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FPPC Form 410(Dec/2012)
FPPC Advice:advice@fppc.ca.gov(866/275-3772)
www.fppc.ca.gov
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,Statement of Organization CALIFORNIA
Recipient Cor"mittee FORM
INSTRUCTIONS ON REVERSE
Page 3
} COMMITTEE NAME 17.NUMBER
Tasha Boerne.r Horvath for Council 2016
General Purpose Committee 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 BRIEF DESCRIPTION OF ACTIVITY
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List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFIUATION OF SPONSOR
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STREET ADDRESS NO.AND STREET CITY STATE ZIP CODE
Small Contributor Committee
Date qualified
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• 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.
FPPC Form 410(Dec/2012)
FPPC Advice:advice@Dfppcca.gov(866/275-3772)
www.fppc.ca.gov
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