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McCormick 460COVER PAGE Recipient Committee Campaign Statement Cover Page Type or print in ink. Date Stamp I (Government Code Sections 84200-84216.5) Statement covers period from 10/01/2012 Date of election if applicable: (Month, Day, Year) SEE INSTRUCTIONS ON REVERSE through __ 1_0'-/ 2_0....:/_2_0_1_2 ___ _ 11/06/2012 1. Type of Recipient Committee: All Committees-Complete Parts 1, 2, 3, and 4. 2. Type of Statement: 3. [i] Officeholder, Candidate Controlled Committee D Primarily Formed Ballot Measure 0 State Candidate Election Committee Committee 0 Recall 0 Controlled {Also Complete Part 5) 0 Sponsored D General Purpose Committee 0 Sponsored 0 Small Contributor Committee 0 Political Party/Central Committee COMMITTEE NAME (Also Complete Part 6) D Primarily Formed Candidate/ Officeholder Committee (Also Complete Part 7) I.D. NUMBER McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 STREET ADDRESS (NO P.O. BOX) ALAMEDA, CA 94501 STATE ZIP CODE MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX STATE ZIP CODE OAKLAND CA 94618 OPTIONAL: FAX I E-MAIL ADDRESS (510) 547-1563 NA AREA CODE/PHONE (510) 547-2451 AREA CODE/PHONE IX] Preelection Statement D Semi-annual Statement D Termination Statement (Also file a Form 410 Termination) D Amendment (Explain below) Treasurer(s) NAME OF TREASURER MARI E. LEE MAILING ADDRESS OAKLAND, CA 94618 NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS CITY OPTIONAL: FAX I E-MAIL ADDRESS STATE STATE D Quarterly Statement D Special Odd-Year Report D Supplemental Preelection Statement -Attach Form 495 ZIP CODE ARE/\ CODE/PHONE (510) 547-2451 ZIP CODE AREA CODE/PHONE 4. Verification I have used all reasonable diligence in preparing and reviewing this statement and to Executed on -------::D::-:a~te ______ _ Executed on -------:=D~at::-e------- By~----------~~~~~~~~~~~~~~~--~--~---------­Signature of Controlling Officeholder, Candidate, State Measure Proponent BY-------~~~~~~~~~~~~~~~~~-~--------­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 Type or print in ink. Recipient Committee Campaign Statement Cover Page-Part 2 5. Officeholder or Candidate Controlled Committee NAME OF OFFICEHOLDER OR CANDIDATE MICHAEL McCORMICK OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) HEALTHCARE DISTRICT BID~RDOBFADARED~ORS 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 I.D. NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? DYES D NO COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE COMMITTEE NAME I.D. NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? DYES D 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 D SUPPORT D 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 offlceholder(s) or candidate(s) for wl1ich this committee is primarily formed. NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD D SUPPORT D OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD D SUPPORT D OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD D SUPPORT D OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD D SUPPORT D OPPOSE Attach continuation sheets if necessary FPPC Form 460 (January/05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) State of California Type or print in ink. SUMMARY PAGE Campaign Disclosure Statement Summary Page Amounts may be rounded to whole dollars. Statement covers period CALIFORNIA 4~ A SEE INSTRUCTIONS ON REVERSE NAME OF FILER McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 Contributions Received ColumnA TOTAL THIS PERIOD (FROM ATTACHED SCHEDULES) 1. Monetary Contributions . . . . . .. . . . . . . . . .. . . . . . . . .. . . . . . . . . .. . . . . . . . Schedule A, Line 3 $ 1,563.50 2. Loans Received ..... ... ....... .... ... .. .... .. .. .. .... ..... .. ...... ... Schedule 8, Line 3 0.00 3. SUBTOTAL CASH CONTRIBUTIONS ... ··-···-·--··-·-··-·--Add Lines 1 + 2 $ 1,563.50 4. Nonmonetary Contributions.................................... Schedule c, Line 3 478.37 5. TOTAL CONTRIBUTIONS RECEIVED ........................... Add Lines 3 + 4 $ 2,041.87 Expenditures Made 6. Payments Made....................................................... Schedule E, Line 4 $ 115.70 7. Loans Made . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . Schedule H, Line 3 0.00 8. SUBTOTAL CASH PAYMENTS .................................... Add Lines 6 + 7 $ 115.70 9. Accrued Expenses (Unpaid Bills) ............................... Schedule F. Line 3 0.00 1 0. Nonmonetary Adjustment .......................................... Schedule c, Line 3 478.37 11. TOTAL EXPENDITURES MADE ................................ Add Lines 8 + 9 + 10 $ 594.07 Current Cash Statement 12. Beginning Cash Balance .. ............. .... .. .. Previous Summary Page, Line 16 $ 1 285.31 13. Cash Receipts ................................................... Column A, Line 3 above 1 563.50 14. Miscellaneous Increases to Cash........................... Schedule I, Line 4 0.00 15. Cash Payments.................................................. Column A, Line 8 above 115.70 16. ENDING CASH BALANCE .......... Add Lines 12 + 13 + 14, then subtract Line 15 $ 2,733.11 If this is a termination statement, Line 16 must be zero. 17. LOAN GUARANTEES RECEIVED ...... .. .... .. .... .. ....... Schedule 8, Part 2 $ 0.00 Cash Equivalents and Outstanding Debts 18. Cash Equivalents........................................ See instructions on reverse $ 0.00 19. Outstanding Debts......................... Add Line 2 +Line 9 in Column 8 above $ 1 982.86 from ____ 1 o_1_o_1_1_2_o_1_2 __ _ FORM \,1\1 through ColumnS CALENDAR YEAR TOTAL TO DATE $ 2,962.50 135.86 $ 3,098.36 478.37 $ 3,576.73 $ 365.25 o.oo $ 365.25 1 847.00 478.37 $ 2 690.62 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). 10/20/2012 Page_3 __ of 8 I.D. NUMBER Calendar Year Summary for Candidates Running in Both the State Primary and General Elections 1/1 through 6/30 711 to Date 20. Contributions Received $ ____ _ $ ____ _ 21. Expenditures Made $------$ ____ _ 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) Schedule A Monetary Contributions Received SEE INSTRUCTIONS ON REVERSE 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 DATE RECEIVED FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR (IF COMMITIEE, ALSO ENTER I.D. NUMBER) 10/09/2012 Lena Tarn Alameda, CA 94501 10/10/2012 CEP America Emergency Physician Partners Emeryville, CA 94608 10/10/2012 Anne B. Blanchette Columbia, SC 29223 10/16/2012 Honora M. Murphy Alameda, CA 94501-3727 Alameda, CA 94501 Schedule A Summary 1. Amount received this period-itemized monetary contributions. CODE* [X]IND DCOM DOTH DPTY DSCC DIND DCOM [KlOTH DPTY DSCC ffiJ IND DCOM DOTH DPTY DSCC ffi) IND DCOM DOTH DPTY DSCC DIND DCOM ffi}OTH DPTY DSCC IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (IF SELF-EMPLOYED, ENTER NAME OF BUSINESS) City Councilmember City of Alameda Homemaker NA Retired NA SUBTOTAL$ SCHEDULE A from 10/01/2012 Statement covers period CALIFORNIA 461"'1 FORM \,J through 10/20/2012 Page __ 4.::..__ of 8 I.D. NUMBER AMOUNT RECEIVED THIS PERIOD CUMULATIVE TO DATE CALENDAR YEAR (JAN. 1 -DEC. 31) PER ELECTION TO DATE (IF REQUIRED) 100.00 750.00 100.00 100.00 150.00 1,200.001 100.00 G 12 750.00 Gl2 100.00 G 12 100.00 G 12 150.00 G 12 *Contributor Codes IND -Individual 100.00 750.00 100.00 100.00 150.00 (Include all Schedule A subtotals.) ........................................................................................................ $ -----=1'-''-=2-=o-=o.::..·-=o-=o-COM-Recipient Committee (other than PTY or SCC) OTH-Other (e.g., business entity) PTY-Political Party 2. Amount received this period-unitemized monetary contributions of less than $100 ............................. $ _____ 3_6_3_._5_o_ 3. Total monetary contributions received this period. SCC-Small Contributor Committee (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1.) ....................... TOTAL $ ------'1'-'''-'5-=6:..:3:...:·-=5-=o- FPPC Form 460 (January/05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) Schedule B-Part 1 Loans Received SEE INSTRUCTIONS ON REVERSE 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 FULL NAME, STREET ADDRESS AND ZIP CODE OF LENDER (IF COMMITIEE, ALSO ENTER 1.0. NUMBER) Wilma Chan Alameda, CA 94501 Paid Printing Bill t!Kl IND 0 coM 0 OTH o PTY 0 sec to IND o coM o orH o PTY o sec to IND o coM o orH o PTY o sec Schedule B Summary IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (IF SELF-EMPLOYED, ENTER NAME OF BUSINESS) Supervisor County of Alameda a OUTSTANDING BALANCE BEGINNING THIS PERIOD 135.86 SUBTOTALS $ (b) AMOUNT RECEIVED THIS PERIOD 0.00 0. 00 $ Statement covers period from 10/01/2012 through __ 1 0_1_2_0_1_2_0_1_2 __ _ (c) AMOUNT PAID OR FORGIVEN THIS PERIOD* 0PAID 0.00 0 FORGIVEN 0.00 0PAID 0 roRGIVEN 0PAID 0 FORGIVEN 0.00 $ (d) OUTSTANDING BALANCE AT CLOSE OF THIS PERl D 135.86 DATE DUE DATE DUE DATE DUE 135.86 (e) INTEREST PAID THIS PERIOD ___ % RATE 0.00 ___ % RATE ___ % RATC $ o. 00 1 (Enter (e) on Schedule E, Line 3) SCHEDULE B-PART 1 CALIFORNIA 461'\\ FORM \.:1 Page __ s_ of __ s_ J.D. NUMBER (f) ORIGINAL AMOUNT OF LOAN 135.86 09/06/2012 DATE INCURRED DATE INCURRED DATE INCURRED (g) CUMULATIVE CONTRIBUTIONS TO DATE CALENDAR YEAR 135.86 PER ELECTION** G12 135.86 CALENDAR YEAR PER ELECTION ** CALENDAR YEAR PER ELECTION** 1. Loans received this period .................................................................................................................... $ o.oo (Total Column (b) plus unitemized loans of less than $1 00.) 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.) ............................................................... NET $ Enter the net here and on the Summary Page, Column A, Line 2. *Amounts forgiven or paid by another party also must be reported on Schedule A. ** If required. 0.00 0.00 (May be a negative number) 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) ScheduleC Nonmonetary Contributions Received SEE INSTRUCTIONS ON REVERSE 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 DATE RECEIVED FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR (IF COMMITTEE, ALSO ENTER I.D. NUMBER) 10103 ;2012 City of Alameda Democratic Club California PA (#1275389) San Francisco, CA 94111 IF AN INDIVIDUAL, ENTER CONTRIBUTOR OCCUPATION AND EMPLOYER CODE* DIND I!] COM DOTH DPTY DSCC DIND DCOM DOTH DPTY DSCC DIND DCOM DOTH DPTY DSCC DIND DCOM DOTH DPTY DSCC (IF SELF-EMPLOYED, ENTER NAME OF BUSINESS) Attach additional information on appropriately labeled continuation sheets. Schedule C Summary 1. Amount received this period-itemized nonmonetary contributions. SCHEDULEC Statement covers period CALIFORNIA 46"' from 10/01/2012 through 10/20/2012 DESCRIPTION OF GOODS OR SERVICES Mailer SUBTOTAL$ AMOUNT/ FAIR MARKET VALUE 478.37 478.37 FORM \I Page _6 __ of __ 8 _ I.D.NUMBER CUMULATIVE TO DATE CALENDAR YEAR (JAN 1-DEC 31) PER ELECTION TO DATE (IF REQUIRED) 478.37 G12 4 78. 3" *Contributor Codes INO -Individual (Include all Schedule C subtotals.) ..................................................................................................................... $ ----'-47;_:8'-'-.-"-37'----COM -Recipient Committee (other than PTY or SCC) OTH Other (e.g., business entity) PTY-Political Party 2. Amount received this period-unitemized nonmonetary contributions of less than $100 .................................... $ _____ 0 _· o_o __ 3. Total nonmonetary contributions received this period. SCC-Small Contributor Committee (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Lines 4 and 10.) ...................... TOTAL $ ____ 4_7 _8 _·_37 __ FPPC Form 460 (January/05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) SeHEDULEE ScheduleE Payments Made Type or print in ink. Amounts may be rounded to whole dollars. from 10/01/2012 Statement covers period CALIFORNIA. 46 A FORM \,1 SEE INSTRUCTIONS ON REVERSE through _1_0_/_2_0:_/ 2_0_1_2 __ _ Page __ 7_ of _a __ NAME OF FILER I.D. NUMBER McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CIVP campaign paraphernalia/misc. MBR member communications RAD radio airtime and production costs eNS campaign consultants MTG meetings and appearances RFD returned contributions eTB contribution (explain nonmonetary)* OFe office expenses SAL campaign workers' salaries eve civic donations PET petition circulating TEL t.v. or cable airtime and production costs FIL candidate filing/ballot fees PHO phone banks TRe candidate travel, lodging, and meals FND fundraising events POL polling and survey research TRS staff/spouse travel, lodging, and meals IND independent expenditure supporting/opposing others (explain)* POS postage, delivery and messenger services TSF transfer between committees of the same candidate/sponsor LEG legal defense PRO professional services (legal, accounting) VOT voter registration LIT campaign literature and mailings PRT print ads WEB information technology costs (internet, e-mail) NAME AND ADDRESS OF PAYEE (IF COMMIITEE, ALSO ENTER I. D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID * Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 0.00 Schedule E Summary 1. Itemized payments made this period. (Include all Schedule E subtotals.) .............................................................................................................. $ _____ o'""'.'""'o""""o_ 2. Unitemized payments made this period of under $100 .......................................................................................................................................... $ ____ .::.1::.:15::..;·:...:7-=o- 3. Total interest paid this period on loans. (Enter amount from Schedule B, Part 1, Column (e).) ............................................................................... $ _____ 0_· 0_0_ 4. Total payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.) ............................. TOTAL $ ____ .::.l=-15._._7_0_ FPPC Form 460 (January/05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) SCHEDULE F Schedule F Accrued Expenses (Unpaid Bills} Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period from 10/01/2012 CALIFORNIA 4611\ FORM \;1 SEE INSTRUCTIONS ON REVERSE through --'1'-'0'-'-/-"'2-"0.!../!:.-2 '"-0 1"-'2"-----Page __ 8_ of_8 __ NAME OF FILER I.D.NUMBER McCORMICK FOR CITY OF ALAMEDA HEALTHCARE DISTRICT BOARD OF DIRECTORS 2012 CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. Cfv'P campaign paraphernalia/misc. MBR member communications RAD radio airtime and production costs CNS campaign consultants MTG meetings and appearances RFD returned contributions CTB contribution (explain nonmonetary)* OFC office expenses SAL campaign workers' salaries CVC civic donations PET petition circulating TEL t.v. or cable airtime and production costs FIL candidate filing/ballot fees PHO phone banks TRC candidate travel, lodging, and meals FND fundraising events POL polling and survey research TRS staff/spouse travel, lodging, and meals IND independent expenditure supporting/opposing others (explain)* POS postage, delivery and messenger services TSF transfer between committees of the same candidate/sponsor LEG legal defense PRO professional services {legal, accounting) VOT voter registration LIT campaign literature and mailings PRT print ads WEB information technology costs (internet, e-mail) NAME AND ADDRESS OF CREDITOR (IF COMMITIEE, ALSO ENTER 1.0. NUMBER) J. Michael McCormick Alameda, CA 94501 Registrar of Voters, Alameda County * Payments that are contnbut1ons or mdependent expenditures must also be summarized on Schedule D. Schedule F Summary CODE OR (a) OUTSTANDING DESCRIPTION OF PAYMENT BALANCE BEGINNING OF THIS PERIOD OFC Reimbursement for 1,847.00 Filing Fee SUBTOTALS$ 1,847.00 $ 1. Total accrued expenses incurred this period. (Include all Schedule F, Column {b) subtotals for (b) (c) (d) AMOUNT INCURRED AMOUNT PAID OUTSTANDING THIS PERIOD THIS PERIOD BALANCE AT CLOSE (ALSO REPORT ON E) OF THIS PERIOD 0.00 0.00 1,847.00 0.00$ o.oo$ 1,847.00 accrued expenses of $100 or more, plus total unitemized accrued expenses under $1 00.) ............................................ INCURRED TOTALS$ -------"-o""'. o,_,o,__ 2. Total accrued expenses paid this period. (Include all Schedule F, Column (c) subtotals for payments on accrued expenses of $100 or more, plus total unitemized payments on accrued expenses under $1 00.) ................................. PAID TOTALS$ ______ o_. 0_0_ 3. Net change this period. (Subtract Line 2 from Line 1. Enter the difference here and on the Summary Page, Column A, Line 9.) ................................................................................................................................................ NET$ ....-::::-:-r:::-:::-::-=;::::-:::-:-o::::'i. o:::::o::- May be a negative number FPPC Form 460 (January/05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)