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COVER PAGE <br /> Recipient Committee Type or print in ink. Date Stamp CALIFORNIA 460 <br /> Campaign Statement FORM <br /> Cover Page <br /> (Government Code Sections 84200-84216.5) Page 1 of 14 <br /> Statement covers period Date of election if applicable: <br /> 9/20/09 (Month, Day,Year) For Official Use Only <br /> from <br /> SEE INSTRUCTIONS ON REVERSE through 10/17/09 11/3/09 <br /> 1. Type of Recipient Committee: All Committees—Complete Parts 1,2,3,and 4. 2. Type of Statement: <br /> ® Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure ® Preelection Statement ❑ Quarterly Statement <br /> 0 State Candidate Election Committee Committee ❑ Semi-annual Statement ❑ Special Odd-Year Report <br /> 0 Recall Q Controlled ❑ Termination Statement ❑ Supplemental Preelection <br /> (Also Complete Part 5) 0 Sponsored (Also file a Form 410 Termination) Statement-Attach Form 495 <br /> (Also Complete Part 6) ❑ Amendment(Explain below) <br /> ❑ General Purpose Committee <br /> 0 Sponsored ❑ Primarily Formed Candidate/ <br /> 0 Small Contributor Committee Officeholder Committee <br /> 0 Political Party/Central Committee (Also Complete Part 7) <br /> 3. Committee Information I.D. NUMBER Treasurer(s) <br /> 1313963 <br /> COMMITTEE NAME(OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER <br /> JOHN SEYBERT FOR CITY COUNCIL 2009 RICHARD S. CLAIRE <br /> MAILING ADDRESS <br /> SAME <br /> STREET ADDRESS(NO P.O.BOX) CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br /> CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY <br /> REDWOOD CITY CA 94062 <br /> MAILING ADDRESS(IF DIFFERENT) NO.AND STREET OR P.O. BOX MAILING ADDRESS <br /> CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE <br /> OPTIONAL: FAX/E-MAIL ADDRESS OPTIONAL: FAX/E-MAIL ADDRESS <br /> 4. Verification <br /> I have used all reasonable diligence in preparing and reviewing this statement and to the best of m . owledge the••form ion contained herein and in the attached schedules is true and complete. I certify <br /> under penalty of perjury under the laws of the State of California that the foregoing is true and . ,t/ <br /> '�� A.tom. <br /> Executed on 10/21/09 BY S gnatu' _ �surer <br /> Executed on ( a By <br /> Si. - on - • ceholder,Candie,'=t= j'asure- •ponent or Responsible Officer of Sponsor <br /> • <br /> Executed on By �^ar-te,State Measure Proponent <br /> Date Signature of Controlling Officeholder, <br /> Executed on By Signature of Controlling Officeholder,Candidate,State Measure Proponent Date FPPC Form 460(January/05) <br /> FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772) <br /> State of California <br />