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McCormick 460Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200-84216.5) SEE INSTRUCTIONS ON REVERSE Type or print in ink. Statement covers period from 01/01/2012 through 09/30/2012 1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4. Officeholder, Candidate Controlled Committee 0 State Candidate Election Committee 0 Recall (Also Complete Part 5) El General Purpose Committee 0 Sponsored o Small Contributor Committee 0 Political Party/Central Committee 3. Committee Information El Primarily Formed Ballot Measure Committee o Controlled 0 Sponsored (Also Complete Part 6) El Primarily Formed Candidate/ Officeholder Committee (Also Complete Part 7) 11.D, NUMBER COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 CITY STATE ZIP CODE AREA CODE/PHONE ALAMEDA( CA 94501 (5101 547-2451 DIFFERENT) NO. AND STREET OR P.O. BOX 436 LOCKSLEY AVE. CITY STATE OAKLAND. CA 4618 OPTIONAL: FAX / E-MAIL ADDRESS NA 4. Verification ZIP CODE AREA CODE/PHONE Date Stamp OCT - 2 Date of election if applicable: (Month, Day, Year) 11/06/2012 CALIFORNIA COVER PAGE CITY OF ALAMELA CITY CLERK'S OFPrtg of For Official Use Only 2. Type of Statement: [i] Preelection Statement El Semi-annual Statement El Termination Statement (Also file a Form 410 Termination) El Amendment (Explain below) Treasurer(s) NAME OF TREASURER MARI 5. LEE MAILING ADDRESS CITY OAKLAND, CA 94618 NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS CITY OPTIONAL: FAX 1 E-MAIL ADDRESS El Quarterly Statement 1:1 Special Odd-Year Report El Supplemental Preelection Statement - Attach Form 495 STATE ZIP CODE STATE ZIP CODE AREA CODElPHONE (510) 547-2451 AREA CODE/PHONE I have used all reasonable diligence in preparing and reviewing this statement Responsible Officer ol Sponsor Signature of Controlling Officeholder, Candidate, State Measure Proponent Signature of Controlling Officeholder, Candidate, State Measure Proponent FPPC Form 460 (January/05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) State of California Recipient Committee Campaign Statement Cover Page — Part 2 10111191.... 017■114111Z■111011■0. 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE MICHAEL McCORMICK Type or print in ink. OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) HEALTHCARE DISTRICT BW DOBFADAMEDZIORS RESIDENTIAL/BUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP ALAMEDA , CA 94501 Related Committees Not Included in this Statement: List any committees not included in this statement that are controlled by you or are primarily formed to receive contributions or make expenditures on behalf of your candidacy. COMMITTEE NAME NAME OF TREASURER COMMITTEE ADDRESS CITY COMMITTEE NAME I.D. NUMBER CONTROLLED COMMITTEE? O YES LJ NO STREETADDRESS (NO P.O. BOX) STATE ZIP CODE AREA CODE/PHONE ID NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? O YES 0 NO COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE 6. Primarily Formed Ballot Measure Committee NAME OF BALLOT MEASURE BALLOT NO, OR LETTER JURISDICTION COVER PAGE - PART 2 CALIFORNIA 460 FORM O SUPPORT O OPPOSE Identify the controlling officeholder, candidate, or state measure proponent, if any. NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY 7. Primarily Formed Candidate/Officeholder Committee List names of officeholder(s) or candidate(s) for which this committee is primarily formed. NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD Attach continuation sheets if necessary [3 SUPPORT 0 OPPOSE O SUPPORT 0 OPPOSE El SUPPORT 0 OPPOSE O SUPPORT O OPPOSE FPPC Form 460 (January/05) FPPC Toll-Free lielplIne: 866/ASK-FPPC (866/275-3772) State of California Campaign Disclosure Statement Summary Page Type or print in Ink. Amounts may be rounded to whole dollars. SEE INSTRUCTIONS ON REVERSE NAME OF FILER McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 Statement covers period from through 01/01/2012 09/30/2012 SUMMARY PAGE CALIFORNIA 460 FORM Page 3 of I.D. NUMBER 8 Contributions Received 1. Monetary Contributions Schedule A, Line 3 $ 2. Loans Received Schedule B, Line 3 3. SUBTOTAL CASH CONTRIBUTIONS Add Lines 1 +2 $ 4. Nonmonetary Contributions Schedule C, Line 3 5, TOTAL CONTRIBUTIONS RECEIVED Add Lines 31-4 $ Column A TOTAL THIS PERIOD (FROM ATTACHED SCHEDULES) 1,399.00 135.86 1,534.86 0.00 1,534.86 Expenditures Made 6, Payments Made Schedule E, Line 4 $ 7. Loans Made Schedule 11, Line 3 8. SUBTOTAL CASH PAYMENTS ........ ......... .... ....... Add Lines 6 + 7 9. Accrued Expenses (Unpaid Bills) Schedule F, Line 3 10. Nonmonetary Adjustment Schedule C, Line 3 11. TOTAL EXPENDITURES MADE Add Lines 8 + 9 + 10 $ $ Current Cash Statement 12. Beginning Cash Balance Previous Summary Page, Line 16 $ 13. Cash Receipts Column A, Line 3 above 14. Miscellaneous Increases to Cash Schedule 1, Line 4 15. Cash Payments Column A, Line 8 above 16. ENDING CASH BALANCE Add Lines 12 + 13 + 14, then subtract Line 15 $ If this is a termination statement, Line 16 must be zero. 249.55 0.00 249.55 1,847.00 0.00 2,096.55 0.00 1,534.86 0.00 249.55 1,285.31 Column B CALENDAR YEAR TOTAL TO DATE 1,399.00 135.86 1,534.86 0.00 1,534.86 249.55 0.00 249.55 1,847.00 0.00 2.096.55 Calendar Year Summary for Candidates Running in Both the State Primary and General Elections 1/1 through 6/30 20. Contributions Received 21. Expenditures Made 7/1 to Date 17. LOAN GUARANTEES RECEIVED Schedule 8, Part 2 $ Cash Equivalents and Outstanding Debts 18. Cash Equivalents... ........ .............. .............. . See instructions on reverse $ 19. Outstanding Debts . Add Line 2 + Line 9 in Column 8 above $ 0.00 0.00 1,982.86 To calculate Column B, add amounts in Column A to the corresponding amounts from Column B of your last report. Some amounts in Column A may be negative figures that should be subtracted from previous period amounts. If this is the first report being filed for this calendar year, only carry over the amounts from Lines 2, 7, and 9 (if any). Expenditure Limit Summary for State Candidates 22. Cumulative Expenditures Made* (If Subject to Voluntary Expenditure Limit) Date of Election (mm/dd/yy) Total to Date *Amounts in this section may be different from amounts reported in Column B. FPPC Form 460 (January/05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) ;chedule A lonetary Contributions Received Type or print iri ink. Amounts may be rounded to whole dollars. EE INSTRUCTIONS ON REVERSE \ME OF FILER IcconMznn FOR CITY OF ALAMEoA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 Statement covers period from 01/01/2012 through 09/30/2012 SCHEDULEA CALIFORNIA 460 FORM Page Page « of I.D. NUMBER 8 DATE RECEIVED FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRUTOR CONTRIBUTOR �c�wm��a/�w��n CODE * 9/14/2012 East Bay Pulmonary Group Alameda, CA 94501 9/27/2012 Eugene Peter savca°oko Alamo, CA 94507-1616 9/26/2012 May Yirig Chen New York, NY 10002 9/06/2012 Edith M. Anderson-Woody ,"zzej°, CA o^uov 9/24/2012 Frank E. Calvaruso Pante vedra Beach, FL 32082 []IND COM OTH PTY scc IF AN NDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (IF SELF-EMPLOYED, ENTER NAME OF BUSINESS) IND Retired OCOM UOTH UPTY LJSCC mm 00TH NA UPTY L]SCC NA Retired El IND COM 00TH County of Alameda OPTY L]SCC Board of Supervisors Staff IND OCOM UOTH [JPTY LJScC Sr. Vice President Guggenheim Investments SUBTOTAL $ chedule A Summary Amountreooivedthispariod — itemizedmonetoryconhibuUona. (lnc)ude all Schedule A subtotals.) � Amount received this period — unitemized monetary contributions of less than $100 � Total monetary contributions received this period. (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1.) TOTAL $ AMOUNT RECEIVED THIS PERIOD 750.00 100.00 100.00 100.00 100.00 1zsoou ' . [� 1,250.00 149.00 1,399.00 oUMuLATmroDATE CALENDAR YEAR 750.00 PER ELECTION TO DATE (IF REQUIRED) G 1 750.00 100.00 G12 100.00 100,00 G12 100.00 100.00 G12 100.00 100.00 G 1 100.00 *Contributor Codes Individual COM — RocpienCpmmittoa (other than PTY or SCC) OTH— Other (o.g, business entity) PTY — Poomm|panY sco— Small Contributor Committee ppPc Form 4anHanuary/0a> pppo Toll-Free *olplino:xVn/ASm'FpPo(oVsmrs-37ro) Schedule A (Continuation Sheet) Monetary Contributions Received NAME OF FILER Type or print in ink. Amounts may be rounded to whole dollars. McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 Statement covers period from 01/01/2012 through 09/30/2012 SCHEDULE A (CONT.) CALIFORNIA FORM Page 5 of 8 I.D. NUMBER DATE FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR RECEIVED (IF COMMITTEE, ALSO ENTER I.D.NUMBER) CODE 09/26/2012 Devender Sharma Alameda, CA 94502 *Contributor Codes IND— Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY — Political Party SCC — Small Contributor Committee El IND ❑ COM ❑ OTH ❑ PTY ❑SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (IF SELF - EMPLOYED, ENTER NAME OF BUSINESS) IT Manager Kaiser Permanente AMOUNT RECEIVED THIS PERIOD 100.00 SUBTOTAL$ 100.00 CUMULATIVE TO DATE CALENDAR YEAR (JAN. 1 - DEC. 31) PER ELECTION TO DATE (IF REQUIRED) 100.00 G12 100.00 FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772) Schedule B - Part 1 Loans Received Type or print in ink. Amounts may be rounded to whole dollars. SEE INSTRUCTIONS ON REVERSE NAME OF FILER McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 11611101■01111122111 FULL NAME, STREET ADDRESS AND ZIP CODE OF LENDER (IF COMMITTEE, ALSO ENTER ID. NUMBER) Wilma Chan Alameda, CA 94501 Paid Printing Bill fgj IND 0 COM 0 OTH 0 PTY D SCC I'D IND 0 COM 0 OTH 0 PTY 0 SCC t0 IND 0 COM El OTH 0 PTY SCC (a) IF AN INDIVIDUAL, ENTER OUTSTANDING OCCUPATION AND EMPLOYER BALANCE (IF SELF-EMPLOYED, ENTER BEGINNING THIS NAME OF BUSINESS) PERIOD Supervisor County of Alameda 0. 00 $ $ SUBTOTALS $ Statement covers period from 01/01/2012 through 09/30/2012 SCHEDULE B PART 1 Page 6 I.D. NUMBER of 8 (b) (c) (d) (0) (f) (9) OUTSTANDING BALANCE AT CLOSE OF THIS PERIOD AMOUNT AMOUNT PAID RECEIVED THIS PERIOD OR FORGIVEN THIS PERIOD* 135.86 135.86 o PAID 0.00 $ o FORGIVEN 0.00 o$ PAID ID FORGIVEN O PAID El FORGIVEN Schedule B Summary 1. Loans received this period $ (Total Column (b) plus unitemized loans of less than $100.) 2. Loans paid or forgiven this period $ (Total Column (c) plus loans under $100 paid or forgiven.) (Include loans paid by a third party that are also itemized on Schedule A.) 3. Net change this period. (Subtract Line 2 from Line 1.) Enter the net here and on the Summary Page, Column A, Line 2. I*Amounts forgiven or paid by another party also must be reported on Schedule A. ** If required. 0.00 135.86 DATE DLIE DATE DUE DATE DUE 135.86 $ 135.86 0.00 NET $ 135.86 (May be a negative number) INTEREST PAID THIS PERIOD RATE RATE RATE 0.00 0.00 (Enter (e) on Schedule E, Line 3) ORIGINAL CUMULATIVE AMOUNT OF CONTRIBUTIONS LOAN TO DATE 135.86 $ 09/06/2012 DATE INCURRED DATE INCURRED DATE INCURRED CALENDAR YEAR 135.86 PER ELECTION** G12 135.86 CALENDAR YEAR PER ELECTION** CALENDAR YEAR PER ELECTION"' tContributor Codes IND—Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY— Political Party SCC — Small Contributor Committee FPPC Form 460 (January/05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) Schedule E Payments Made Type or print in ink. Amounts may be rounded to whole dollars. SEE INSTRUCTIONS ON REVERSE NAME OF FLER McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 Statement covers period from 01/01/2012 SCHEDULEE CALIFORNIA FORM 460 through r uh PagePage of o /.uwuwasx " CODES: If one of the following codes accurately describes the payment, you may enter the code. Othanwma, describe the payment. OVP CNS CTB CVC FIL FND NO LEG LIT campaigmparaphemalia/misc. campaign consultants contribution (explain nonmonetary)* civic donations candidate filing/ballot fneu fundraising events independent expenditure supporting/opposing others (explain)* legal defense campaign iterature and mailings MBR MTG OFC PET PHO POL POS PRO PRT member communications meetings and appearances office expenses petition circulating phone banks polUng and survey research pnotago, delivery and messenger services professional services (|ege/, accounting) print ads RAD RFD SAL TEL 'TRC TRS TSF VDT WEB NAME AND ADDRESS OF PAYEE (IF COMMI11 6E, ALSO ENTER I.D. NUMBER) In/Out Printing San Leandro, CA 94577 CODE radio airtime and production costs returned contributions campaign workers' salaries tv. or cable airtime and production costs candidate travet, lodging, and meals staff/spouse travet, lodging, and meals transfer between committees of the same candidate/sponsor voter registration information technology costs (Internet, e-mail) OR DESCRIPTION OF PAYMEN Remits * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $ Schedule EE Summary 1. Itemized payments made this period. (Indude aH Scheduie E subtotals.) � 2. Unitemized payments made this period of under $1 00 � 3. Total interest paid this period on loans. (Enter amountfrom Schedule B, Part 1' Column (e).) 4. Tota payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.) � AMOUNT PAID 222.55 222.55 222.55 27.00 0.00 TOTAL $ 249.55 FPPC Form 460 (January/05) Schedule F Accrued Expenses (Unpaid Bills) Type or print in ink. Amounts may be rourided to whole dollars. SEE INSTRUCTIONS ON REVERSE NAME OF FILER McCORMICK FOR CITY OF aLmMEoA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 CODES: If one of the foliowing codes accurately describes the cm. campaign paraphernalia/misc. MBR CNS campaign consultants MTG CTB contribution (explain nonmonetary)* OFC CVC civic donations PET FIL candidate fihing/bailot fees PHO FND fundraising events POL IND independent expendlture supportlngfopposlng others (explain)* pos LEG legal defense PRO LIT campaign literature arid mailings PRT 111.01=R111118.. J1111■1110166111■11M.... NAME AND ADDRESS OF CREDITOR (IF COMMITTEE, ALSO ENTER I.O. NUMBER) J. Michael McCormick elameu°, CA 94501 Registrar of wot°,", Alameda County * Payments that are contributions or independent expenditures must also be summarized on Schedu!e D. payment, you may enter the code. member communications meetings and appearances office expenses petition circulating phone banks polling arid survey research pnstego, delivery and messenger services professional services (legal, accounting) print ads CODE OR DESCRIPTION OF PAYMENT Statement covers perio from 01/01/2012 through 09/30/2012 OUhemioe, describe the payment. (a) OUTSTANDING BALANCE BEGINNING OF THIS PERIOD OFC Reimbursement for 0.00 Filing Fee SUBTOTALS $ o'un $ RAD RFD SAL TEL TRC TRS TSF VOT WEB SCHEDULE F CALIFORNIA 460 FORM Page 8 of 8 I.D. NUMBER radio airtime and production costs returned contributions campaign workers' salaries tv. or cable airtime and production costs candidate travel, |odging, and meals staff/spouse travel, |odging, and meals transfer between committees of the same oond|uave/oponoor voter registration information technology costs (internat. e-mail) (b) (c) (d) AMOUNT INCURRED AMOUNT PAID OUTSTANDING THIS PERIOD THIS PERIOD BALANCE AT CLOSE (ALSO REPORT ON E) or THIS PERIOD 1'847,00 0.00 1,847.00 1,847.00 $ 0.00$ 1,847.00 Schedule F Summary 1. Total accrued expenses incurred this period. (Include all Schedule F, Column (b) subtotals for accrued expenses of $100 or more, plus total unitemized accrued expenses under $100.) INCURRED TOTALS $ 2. Total accrued expenses paid this period. (Indude all Schedue F, Column (c) subtotals for payments on accrued expenses of $100 or more, plus total unitemized payments on accrued expenses under $100.) PAID TOTALS $ 3. Net change this period. (Subtract Line 2 from Line 1. Enter the difference here and on the Summary Page, Columri A, Line 9.) z'n*zuo NET $ 1,847.00 May be°negative number FPPC Form 460 (January/05