Pepin for City Council 2022 410 Amendment 11/22/2021Statement of Organization
Recipient Committee
Statement Type
Date Stamp
NCI.''. ` .
Ciriycfpow
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CALIFORNIA 4' 0
FORM
For OffciatUse Ony
0 Initia1
❑ Not yet qualified
or
Q Date qualificitiar threshold met
!
51 Amendment
Date qualification threshold met
08 O5,.-.,J 2A21
❑ Termination
-
— See Part 5
Date ofterminatian
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1. Committee Information I.O. Number 1439479
!'o..Gro54e1
2. Treasurer and
Other Principal Officers
NAME OF COMMITTEE
Pepin for City Council2022
NAME Of TREASURER
Briana Baleskie
STREET ADDRESS (NO PO. BOx1
STREET ADDRESSING P.O. BOX)
CITY STATE 21P CODE AREA CODE/PHOHE
Imperial Beach CA 91932
CRY STATE ZIP CODE AREA CODE/PHONE 1
Poway CA 92064
NAME OF ASSISTANT TR EASIIR ER, IF ANY
FULL MAILING ADDRESS IF DIFFERENT I
Imperial Beach, CA 91932
Si aF ET ADDRESS (ND PO. BO]f)
E-MAIL ADDRESS i REOUIRED}J=A%(OPTIONAL}
CITY STATE ZIPCODE AREACOJE/PHONE
COUNTY Of DOMICILE
San Diego County
JURISDICTION WHERE COMMITTEE IS ACTIVE
City of Poway - District 1
NAME OF PRINCIPAL OF PILE MS}
Attach additional information on appropriately labeled continuation sheets.
STREET ADDRESSING P.O. BOx1
C!TT STATE ZIP CODE AREA CODE/PNO NE
3. Verification
have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and complete. 1 certify under
penalty of perjury under the laws of the State gfQlifornia the foregoing is true and correct.
//// 5 / G (
Executed on
Executed on
Executed on
Executed on
DATE
DATE
By
cI r. van IR o n c TREASURER OR ASSISTANT TREASURER
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
DATE
SIGNATURE OF CONTROLLING OFFICEHOL DER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (August/2018)
FPPC Advice: advice(fpoc-ca.gov (866/275-3772)
www.fppc.ca.goy
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
CALIFORNIA 410
FORM
Page 2
COMMITTEE NAME
Pepin for City Council 2022
I.D. NUMBER
1439479
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
Bank of San Francisco
AREA CODE/PHONE
415.744.6700
BANK ACCOUNT NUMBER
ADDRESS
575 Market Street, Ste 900
CITY
San Francisco
STATE
CA
ZIP CODE
94105
4. Type of Committee Complete 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." 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
(INCLUDE DISTRICT NUMBER IF APPLICABLE)
YEAR OF
ELECTION
PARTY
CHECK ONE
Brian Pepin
Poway City Council - District 1
2022
Nonpartisan
i
Partisan
(list political party below)
Nonpartisan
Partisan
(list political party below)
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) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE `RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT
OPPOSE
SUPPORT
OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advicePfppc.ca.J;ov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Pepin for City Council 2022
1.0. NUMBER
1439479
4. Type of Committee (Continued)
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
Sponsored Committee
List additional sponsors on an attachment.
NAME OF SPONSOR
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS
NO. AND STREET
CITY
STATE
ZIP CODE AREA CODE/PHONE
Small Contributor Committee
❑ //
Date qualified
5. Termination Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, 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 are subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410 (August/2018)
FPPC Advice: advicePfppc.ca.gov (866/275-3772)
www.fppc.ca.gov