Form 410 Initial 09-09-20229/9/22, 7:19 PM
20220908111935.jpg
CITY OF ENCIii,
T-CLER
statement of organizgkM 4
Recipient Cornmifte
22 SEP 12 AM 7
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Marie Davis
soRErTAvdeass pro so. AgxL
Encinitas
CA
92024
N—f Cy AMMANT TUAW.Rk IT ANY
CA 9.0924 $
Eli Stern
STREET n JOms No CO, Dom
CITY
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r4 coot
Encinitas
CA
92024
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San Dwg4
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preparing thra
Of Californiae-entanthat thj`tOt eDe"O'Myknow ledge rneintOrMadonc6—nTained herein Istrue ardCOmplete, lFeMTYunder
Penalty ofP4,JUN Under the laws oftiv, Start, e oreis goinand correct.
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"PC A4vje*:rPPC Form 410 (August/20,S)
(866/27S-3772)
Oman
https:Hmai1.google.com/mai1/u/0/?shva=1&zx=IbeImncrvlks&pii=1#sent/KtbxLthRTjZRVvqgHCbCrRNGMJKbWddJPg?projector=1&messagePart]d=0.1 1/1
Statement of Organization CALIFORNIAt
Recipient Committee • -
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D. NUMBER
Stacie Davis For Encinitas City Council 2022
All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
US BANK 760-632-3620
ADDRESS CITY STATE ZIP CODE
131 N El Camino Real 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 the year of the election.
• List the political party with which each officeholder or candidate is affiliated or check "nonpartisan." Stating "No party preference" is acceptable
• 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 YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION CHECK ONE
Stacie Davis
Encinitas City Council 2022 District 4
2022
Nonpartisan
Partisan
(list political party below)
4/
Democrat
Nonpartisan
Partisan
(list political party below)
• 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
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advJce@fppc.ca.gov (866/275-3772)
www.fraiac.ca.gOv_
Statement of Organization (,
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D. NUMBER
Stacie Davis For Encinitas City Council 2022
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
List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
CITY
BY GROUP OR AFFILIATION OF SPONSOR
STATE ZIP CODE AREA CODE/PHONE
— 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 (August/2018)
FPPC Advice: advice(€aac.ca.av (866/275-3772)
www. ppf.ca.€ av
Peter Weichers
From: Kathy Hollywood
Sent: Monday, September 12, 2022 8:51 AM
To: City Clerk
Subject: FW: Stacie Davis Fixed Form 410
Attachments:
StacieDavisFixed Form 410 Page1.pdf; Fixed Form 410 Stacie Davis Parts 2-3.pdf
Kathy Hollywood
City Clerk, City of Encinitas
505 S. Vulcan Avenue, Encinitas, CA 92024
760.633.2601
kholllywood((D,encinitasca.gov
www,encinitasca.gov
Correspondents should be aware that all communications to and from this address are subject to public
disclosure and may be reviewed by third parties.
From: Stacie Davis <staciedavis@4encinitas.com>
Sent: Friday, September 9, 2022 7:24 PM
To: Kathy Hollywood <khollywood@encinitasca.gov>
Subject: Stacie Davis Fixed Form 410
[NOTICE: Caution: External Email]
Kathy attached is my fixed 410 form
For your records.
Thanx
Sent from Mail for Windows
vLc•wlllcnL VI W1! d111LdL1VF1
Recipient Committee
Date Stamp CALIF• -
NIA
410
Statement Type Minitial ❑ Amendment ❑ Termination — See Part 5
FORM
For Official Use Only
CITY OF ENClP1l7A
Not yet qualified
I
CITY CLERK
or
Q Date qualification threshold met Date qualification threshold met
Date of termination
1tg*�
20 2 AUG 22 PH 12: 1
• • I.D. Number
• • -
(i applicable)
NAME OF COMMITTEE
7NAM�
DCIL
STREET ADD NO P. .BOX)
l
ADDRESS (NO P.O. BOX) ,�
CITY-- STATE ZIP CODE AREA CODE/PHONE
ry
.tl- -j � A-
i � 11
SATE ZIP CODE AREA CODE/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
F LL MAILING ADDRESS (IF DIFFERENT)
��,�r
STREET ADDRESS (NO .0. BOX)'
i; _ j
CODE/PHONE
JURISDICTION WHERE COMMITTEE IS ACTIVE
NAME OF PRINCIPAL OFFICER(S)
STREET ADD ESS (NO P,O. BOX) j
�IC
Attach additional information on a
f appropriately labeled continuation sheets.
CITY STATE ZIP CODE AREA CODE/PHONE
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is t-ue and complete. I certify under
penalty of per'ury under the
-laws
)of the State of California that the o going4s true and orrect.
Executed on �ILi G(�pS� ,� %�
BY �'� 1/ V V -11-1
DATY SIGNAT E OFTR r
U ER OR ASSISTANT TREASURER
Executed on y AL—
SIGNATURE�
DATE '
OF CONTROLLING OFFICENULDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on ItBy
DATE
EXecuted on
�11 I.rvAIUKE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR iTKI E MEASURE PROPONENT
By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (August/2018)
FPPC Advice: advice0fopc ca gov (866/275-3772)
www.fppc.Ca.gov
Statement of Organization CALIFORNIA
Recipient Committee FORM
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME, �--- s I. . NUMBER
Jr,
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
ADDRESS CITY - STATE j ZIP CODE
n- It] lkE ` t 'S
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." Stating "No party preference" is acceptable
• If this committee acts jointly with another controlled committee, list the name and identification number o` the other controlled committee.
ELECTIVE OFFICE SOUGHT OR HELD YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLF1 ELECTION rwrry nmr
t
t y
Nonpartisan
Partisan
(list political parry below)
Nonpartisan
Partisan
ist political party below)
Primarily Formed Committee IIIIIIII 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) OFF',CE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT OPPOSE
SUPPORT OPPOSE
J
FPPC Form 410 (August/2018)
FPPC Advice: advice fppc.ca.gov (866/275-3772)
www.fPPC.Ca.gO
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
21 CITY Committee ❑ COUNTY Committee ❑ STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
CITY
DUSTRY GROUP OR AFFILIATION OF SPONSOR
Page 3
I.D. NUMBER
STATE ZIP CODE AREA CODE/PHONE
Date qualified
S. Termin4666 Requlrenlerlts By signing the verification, the treasurer, assistant treasurer and/or candidate,,ffit-eholder, or ponent certify that all of the following conditions 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 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 aretubject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.eov (866/275-3772)
www.foac.ca.gov
a___, i-) i ;L4nL4 1 snow
Statement of Organization
Date Stamp
CALIFORNIA
Committee L—lyd!4{jj{.....-.
��, t
-
'Recipient
Statement Type ® Initial ❑ Amendment
❑ Termination — See Part 5 111"°
ft
of
o t ®6fis�r�t�ry ,
Stag of �alifarnia
QrtAe�Diy
f T Y Cf.j�
0 Not yet qualified
or
c� �j qq
P � 2 �n�ZZQ22
t� ^s
GT i!
�� 3� 55
Q) Date qualification threshold met Date qualification threshold met
Date of termination
9 � 12022
Committee1.
2. Treasurer and Other PrincipalOfficers
1 op livable)
NAME OF COMMITTEE
NAME OF TREASURER
Stacie Davis For Encinitas City Council 2022
Stacie Davis
STREET ADDRESS (NO P.O. BOX)
STREET ADDRESS (NO RO. BOX)
CITY
STATE
ZIP CODE
AREA CODE/PHONE
Encinitas
CA
92024
CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
Encinitas CA 92924
Eli Stern
FULL MAILING ADDRESS (IF DIFFERENT)
STREET ADDRESS (NO PO. BOX)
'
E-MAIL ADDRESS (REQUIRED)/ FAX (OPTIONAL)
CITY
STATE
ZIP CODE
AREA CODE/PHONE
StacieDavis@4Encinitas.com
Encinitas
CA
92024
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/PHONE
3. Verification
I Ilavc uzcu all Icaaullau— ufu6cn4c III VIcPGII Ll16 LIII] xaLCIIICI IL UIIU LU LIIC UCaI UI Illy NIIUWICUrc LIIC IIIIUI II IdLIUII UUIILdIIICU IICICIII Ib LIUC drlu CUTTIIplele. I CerriTy uncier
penalty of perjury under the laws of the State of California that the oregoing is true and correct.
Executed on 9/7/2022 By
DATE 9/7/2022 �v vl SIGNXTTRE OF T�YAS�IRER OR ASSISTANT TREASURER
DATE SIG
Executed on By
p�YYY-/ /\I
NAT RE OF CONTROLLING OFFILMOOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on I By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 420 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/27S-3772)
www.fppc.ca.aov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Stacie Davis For Encinitas City Council 2022
All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
US BANK
ADDRESS
131 N El Camino Real
AREA CODE/PHONE
760-632-3620
CITY
Encinitas
BANK ACCOUNT NUMBER
STATE 21P CODE
CA 92024
Page 2
I.D. NUMBER
• 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." Stating "No party preference" is acceptable
• 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 YEAR OF
(INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION PARTY
Stacie Davis CHECK ONE
Encinitas City Council 2022 District 4 2022 Nonpartisan Partisan (list political party below
✓ Democrat
Nonpartisan Partisan
(list political Party below,
■Primarily formed to support or op
pose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE "RECALL- IN FRONT OF THE OFFICEHOLDER'S NAME. CANDIDATE(S) OFFICE SOUGHT IT HELD OR COUNTY,
AS PPLJURISDICTION
{INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT OPPOSE
SUPPORT I OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advice tgRpp ca gq (866/275-3772)
w— w. fP c. ca-.R0—v
Statement of Organization
Recipient Committee '
INSTRUCTIONS ON REVERSE
COMMITTEE NAME Page 3
Stacie Davis For Encinitas City Council 2022 I.D. NUMBER
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 OFACTIVITY
"' III List additional sponsors on an attachment.
NAME nc corm -
CTPr— --
Small Contributor, CQmrr�ittee
Date
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
CITY
STATE
• 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,
ZIP CODE AREA CODE/PHONE
— 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 (August/2018)
FPPC Advice: adv_icg@fP-P .ca. ov (866/275-3772)
wvuw.fppc.ca.goy