Form 410 Amendment 02/10/16 Statement of Organization Date Stamp _
Recipient Committee C11-`/ c
Statement Type ❑Initial ® Amendment ❑ Termination'—See Part 5 I�.E y
YP For Official Use Only
List I.D.number: List I.p�m R?b�r EIVED AND F
Not yet qualified ❑ or LUiU rfit� —7 �.
f of Stat
n office of the Secretary
# 1380766 # of the State of California ?nt,{ —.
/--/ 10 114 12015 FEB 22 2016
I
Date qualified as committee Date qualified as committee Date of Termination
(If applicable)
1. Committee Information 2. Treasurer'and.Other Principal Officers
NAME OF COMMITTEE NAME OF TREASURER
Tasha Boerner Horvath.for Council 2016 Simon Mayeski
San Diego CA 92124 858-361-8223
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY
Encinitas CA 92024 760.274.4905 Tasha Boerner Horvath
MAILING ADDRESS(IF DIFFERENT)
FAX/E-MAIL ADDRESS CITY STATE ZIPCODE AREA CODE/PHONE
Encinitas CA 92024 760.274.4905
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(S)
San Diego Encinitas
STREET ADDRESS(NO P.O.BOX)
Attach additional information on appropriately labeled continuation sheets. CITY STATE ZIP CODE AREA CODE/DRONE
3. Veri 'cation
I have used all reasonable diligence in preparing this stat ment 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 Califor ' tha oreg✓�oiin is true and correct.
Executed on 2/10/2016 By ' r
DATE 51 ATU 0 TREASURER OR ASSISTANT TREASURER
Executed on 2/10/2016 By
DATE 4
'51'GNAIV CONT ING EHOLDER,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
FPPC Form 410(Jan/2016)
FPPC Advice:advice @fppc.ca.gov(866/275-3772)
www.fppc.ca.gov
Statement of Organization CALIFORNIA
Recipient Committee FORM
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D.NUMBER
Tasha Boerner Horvath for Council 2016 0 1380766
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
Wells Fargo Bank 1760.479.6600 18813115683
ADDRESS CITY STATE ZIP CODE
687 S. Coast Hwy 101, Ste. #151 Encinitas CA 92024
4.Type of C0111mlttee�;ComPiete 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."
• 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
® Nonpartisan
Tasha Boerner Horvath Encinitas City Council 2016
❑ Nonpartisan
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)FULLTITLE(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
SUPPORT OPPOSE
SUPPORT OPVnSF
FPPC Form 410(Jan/2016)
FPPC Advice:advice @fppc.ca.gov(866/275-3772)
www.fppc.ca.gov