Pepin for City Council 2022 410 Amendment 12/07/2021Statement of Organization
Recipient Committee
Statement Typen
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Date Stamp
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the Office Of the $t eretery •
of the State of California
NOVry
V 18 2021
CALIFORNIA 41
FORM
For Official Use In y
DEC 0 7 2O2
CITY OF POWAY
0ITY
❑ Initial
❑ Not yet qualified
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Q Date qualification threshold met
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® Amendment
Date qualification threshold met
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• Termination — See Part 5
Dale of termination
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1. Committee
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Information I.D. Number
L b •piPcaie
1439479
2. Treasurer and
NAME OF TREASURER
Briana Baleskie
Other Principal Officers
:.' !
NAME OF COMMITTEE
Pepin for City Council 2022
s7R E ET ADDRESS (NO P.O. Box]
STREET ADDRESS (NO P.O. BOX)
CITY
Imperial Beach
STAVE ZIP CODE AREA CODE PHONE
CA 91932
CITY STATE ZIP CODE AREA CODE/PHONE
Poway CA 92064
NAME OF ASSISTANT TREASURER,. IF ANY
FULL MAILING ADDRESS (IF INF F ER ENT)
II perial Beach, CA 91932
STREET ADDRESS (NO P-0, SOX)
EMAIL ADDRESS IREQUERE 011/FAX {OPTIONAL)
CITY
STATE ZIP CODE AREA CODE/PHONE
COUNTY OF DOMICILE
San Diego County
JuRI5OICTION WHERE COMMITTEE ISACTIVE
City of Poway - District 1
NAME OF PRINCIPAL OFFICER(S)
Attach additional information on appropriately labeled continuation sheets.
STREET ADDRESS (NO P.O. BOX)
.'TY
STATE ZIP CODE AREA CODE/PHONE
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 perjuryunder the laws of the Sta e and correct.
Executed on //!/%/ / By
DATE
Executed on { ■ 1 Z 2- By
Executed on
DATE
DATE
ASURER OR ASSISTANT TREASURER
SIG NATURE OF CONTROLLING OFF iCE HOLDS R. CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROL LING O F P ICE HOLOE R, CANDIDATE. OR STATE MEASURE PROPONENT
Executed Dn _ By
PATE
SlG NATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE. OR STATE MEASURE PROPONENT
FP PC Form 410 (August/2018)
FPPC Advice: a dvicetsfvac,ca.gov (866/275-3772)
www.fooc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
CALIFORNIA
410
Page 2
COMMITTEE NAME
Pepin for City Council 2022
1.0. NUMBER
1439479
• All committees must list the financial institution where the campaign bank account is located.
NAME Of FINANCIAL INSTITUTION
Bank of San Francisco
ADDRESS
575 Market Street, Ste 900
AREA CODE/PHONE
415.744.6700
CITY
San Francisco
STATE ZIP CODE
CA
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
1
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: advice(afppc.ca.tov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Pepin for City Council 2022
I.D. 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
0 / /
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.Rov