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City of Los Altos

FPPC CAMPAIGN DISCLOSURE STATEMENT



Name of Committee: Nancy M Carlson

Treasurer: Ted Forsman




DISCLAIMER:
The information contained in these pages is information as submitted by the candidates to the City
Clerk as required by the Political Reform Act of 1974 (amended). The City Clerk does not certify the
accuracy of any information contained in these pages.

The City Clerk reserves the right to modify, update, change or make improvements at any time,
without notice, and assumes no liability for damages incurred directly or indirectly as a result of
errors, omissions or discrepancies.
Recipient Committee
Type or print in ink.
COVER PAGE
.. e.
2: I I .
Date Stamp
2010 ocr -I
I
CITY CL F
Campaign Statement
Cover Page
(Government Code Sections 84200-84216.5)
Statement covers period
from 07/01/2010
through 09/30/2010 SEE INSTRUCTIONS ON REVERSE
1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4.
o Officeholder, Candidate Controlled Committee o Primarily Formed Ballot Measure
o State Candidate Election Committee Committee
o Recall o Controlled
(AlSO Complere ParT 5)
o Sponsored
(AlSO Complete Part 6)
o General Purpose Committee
o Sponsored \Zl Primarily Formed Candidate/
o Small Contributor Committee
Officeholder Committee
IAlso Complete Part T}
o Political Party/Central Committee
1.0. NUMBER
3. Committee Information
1330148
COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE)
NANCY CARLSON FOR CITY COUNCIL 2010
STREET ADDRESS (NO P.O. BOX)
981 Thatcher Drive
CITY STATE ZIP CODE AREA CODE/PHONE
Los Altos CA 94024 650-255-1435
MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX
CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX / E-MAIL ADDRESS
nmcarlsonO 1@yahoo.com
Date of election if applicable:
(Month, Day, Year)
11/02/2010
2. Type of Statement: I I ".
:.., z ,\
I;zI Preelection Statement
o Quarterly Staler'r11"int
o Semi-annual Statement
o Special Odd-Year Report
U Termination Statement
o Supplemental Preelection
(Also file a Form 410 Termination) Statement - Attach Form 495
o Amendment (Explain below)
Treasurer(s)
NAME OF TREASURER
Ted Forsman
MAILING ADDRESS
501 San Felicia Way
CITY STATE ZIP CODE AREA CODE/PHONE
Los Altos CA 94022 650-575-6704
NAME OF ASSISTANT TREASURER, IF ANY
Nancy Carlson
MAILING ADDRESS
981 Thatcher Drive
CITY STATE ZIP CODE AREA CODE/PHONE
Los Altos CA 94024 650-255-1435
OPTIONAL: FAX / E-MAIL ADDRESS
nmcarlson01@yahoo.com
4. Verification
I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information contained herein and in the attached schedules is true and complete I certify
under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
09/27/2010
Executed on
Dale
By \1
09/27/2010
Executed on
By __ ......<; u •••,._nu. __..'o __
Date
Executed on
By rt
Date Sigture of Controlling Officeholder. Candidate, State Measure Proponent
Execu1ed on
Dal.
By ------­
FPPC Fonn 460 (January/OS)
FPPC Toll-Free Helpline: 866IASK-FPPC (866/275-3772)
State of California
Type or print in ink. COVER PAGE - PART 2
Recipient Committee
'-Uti!. De a
Campaign Statement
Cover Page ­ Part 2
of _
5. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee
NAME OF OFFICEHOLDER OR CANDIDATE NAME OF BALLOT MEASURE
Nancy Carlson
BALLOT NO. OR LETTER JURISDICTION
OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) o SUPPORT
o OPPOSE
City Council Member Los Altos
RESIDENTIAl/BUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP
981 Thatcher Drive Los Altos, CA 94024
Identify the controlling officeholder, candidate, or state measure proponent, if any.
NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT
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.
OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
COMMITIEE NAME 1.0. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE?
7. Primarily Formed Candidate/Officeholder Committee List names of
officeholder(s) or candidate(s) for which this committee is primarily formed.
DYES o NO
COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX)
CITY STArE ZIP CODE AREA CODE/PHONE
COMMITTEE NAME '1.0. NUMBER
NAME OF TREASURER CONTROLLED COMMITTEE?
DYES o NO
COMMITTEE ADDRESS STREET ADDRESS (NO PO. BOX)
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
o SUPPORT
o OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
I
o SUPPORT
o OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
o SUPPORT
o OPPOSE
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
o SUPPORT
o OPPOSE
CITY STATE ZIP CODE AREA CODE/PHONE
Attach continuation sheets if necessary
FPPC Form 460 (January/OS)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
State of California
I
Type or print in ink. SUMMARY PAGE
Campaign Disclosure Statement
Amounts may be rounded
Statement covers period
CALIFORNIA 460 Summary Page to whole dollars.
from 07/01/2010 FORM
SEE INSTRUCTIONS ON REVE':lSE
NAME OF FILER
NANCY CARLSON FOR CITY COUNCIL 2010
I
through
1330148
09/30/2010 I 3 7
Page --­ of
ID. NUMBER
Contributions Received
ColumnA
TOTAL THIS PERIOD
(FROM ATTACHED SCHEDULES)
ColumnB
CALENDAR YEAR
TOTAl TO DATE
Calendar Year Summary for Candidates
Running in Both the State Primary and
1. Monetary Contributions . Schedule A. Line 3 $
750
$
750
General Elections
2. Loans Received. . . Schedule B. Line 3
1915.18 1915.18
1/1 through 6/30 7/1 to Date
Add Lines 1 + 2
Schedule C, Line 3
3. SUBTOTAL CASH CONTRIBUTIONS .
4. Nonmonetary Contributions .
$
2665.18
o
$
2665.18
o
20. Contributions
Received $ _
21. Expenditures
$----­
5. TOTAL CONTRIBUTIONS RECEIVED Add Lines 3 + 4 $
2665.18
$
2665.18
Made $ _
$
Add Lines 6 + 7
Schedule E. Line 4
Schedule H, Line 3
8. SUBTOTAL CASH PAYMENTS ..
9. Accrued Expenses (Unpaid Bills) . Schedule F. Line 3
10. Nonmonetary Adjustment SchedufeC.Line3
11. TOTAL EXPENDITURES MADE....... Add Lines 8 + 9 + 10
Expenditures Made
6. Payments Made.
7. Loans Made . .
o
o
o
1745.79
1745.79
1745.79
$
$
$
o
o
o
1745.79
1745.79
1745.79
$
$
$
Total 10 Date
$----­
Date of Election
(mm/dd/yy)
22. Cumulative Expenditures Made'
(If Subject to Volunbry Expenditure Limit)
------l--l__
Expenditure Limit Summary for State
Candidates
$----­
FPPC Form 460 (January/OS)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
'Amounts in this section may be different from amounts
reported in Column B.
. Add Lines 12 + 13 + 14. then subtract Line 15
Column A. Line 8 above
Schedule I. Lme 4
Column A, Line 3 above
Previous Summary Page. Lme 16
If this is a termination statement, Line 16 must be zero.
16. ENDING CASH BALANCE ..
Current Cash Statement
12. Beginning Cash Balance ..
13. Cash Receipts .
14. Miscellaneous Increases to Cash __ .
15. Cash Payments ....
o
919.39
o
1745.79
2665.18
$
$
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).
Schedule B. Part 2 17. LOAN GUARANTEES RECEiVED .
o
$
Cash Equivalents and Outstanding Debts
18. Cash Equivalents See instructions on reverse
Add Line 2 + Line 9 in Column B above 19 Outstanding Debts .
o
1915.18
$
$
460
Schedule A
Type or print in ink.
SCHEDULE A
Amounts may be rounded
Statement covers period
Monetary Contributions Received
to whole dollars.
CALIFORNIA
from 07/01/2010
FORM
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER
NANCY CARLSON FOR CITY COUNCIL 2010
through 09/30/2010
Page 4
I.D. NUMBER
1330148
of 7
PER ELECTION AMOUNT CUMULATIVE TO DATE IF AN INDIVIDUAL. ENTER
FULL NAME. STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR ICONTRIBUTOR
DATE
TO DATE RECEIVED THIS CALENDAR YEAR OCCUPATION AND EMPLOYER
(IFCOMMITIEE.ALSOENTER1.D.NUMBER) CODE *
RECEIVED
(IF REQUIRED) (IF SELF·EMPLOYED. ENTER NAME PERIOD (JAN. 1 - DEC. 31)
OF BUSINESS)
hZllNO
oCOM Retired
$50 $50 08/26/2010 $50
DOTH
oPTY
osee
~ I N O
oeOM Self employed
$50 $50 $50 08/24/2010
DOTH
NCL Associates
oPTY
osee
\;ZJ INO
OCOM General Manager
$100 $100 $100 08/26/2010
DOTH
Monumental Ventures
oPTY
OSCC
{llINO
oeOM CFO
$100 $100 $100 08/30/2010
DOTH Coast RV
oPTY
osee
blIlNO
John and Dani Thompson
Vice President oeOM
$100 $100 $100
DOTH Intero Real Estate
OPTY
osee
09/14/2010
Schedule A Summary -Cuntribulor Codes
1. Amount received this period - itemized monetary contributions.
(Include all Schedule A subtotals.) $
$750
_
IND-Individual
COM - Recipient Committee
(olher than PTY or SeC)
2. Amount received this period - unitemized monetary contributions of less than $100 $ $0
OTH - Other (e.g., business entity)
PTY - Polilical Party
3. Total monetary contributions received this period. $750
sce - Small Contributor Committee
(Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1.) TOTAL $ _
FPPC Form 460 (January/OS)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Schedule A (Continuation Sheet)
Type or print in ink. SCHEDULE A (CaNT)
Amounts may be rounded
Statement covers period Monetary Contributions Received
CALIFORNIA 460 to whole dolla rs.
from 07/01/2010 FORM
through 09/30/2010
Page 5 of 7
NAME OF FILER I.D.NUMBER
NANCY CARLSON FOR CITY COUNCIL 2010 1330148
PER ELECTION AMOUNT CUMULATIVE TO DATE IF AN INDIVIDUAL, ENTER
FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR ICONTRIBUTOR
DATE
TO DATE RECEIVED THIS CALENDAR YEAR OCCUPATION AND EMPLOYER
(IF COMMITIEE. ALSO ENTER I.D. NUMBERj CODE *
RECEIVED
(IF SELF·EMPLOYED. ENTER NAME (IF REQUIRED) PERIOD (JAN. 1 • DEC 31)
OF BUSINESS)
IllIND
William and Maria Lonergan
OCOM
09/20/2010
DOTH
DPTY
DSCC
IllIND
OCOM
09/21/2010
DOTH
DPTY
Dscc
IllIND
DCOM
08/3012010
DOTH
DPTY
Dscc
Software Sales
$100 $100 $100
OfferPal, Media
Product Designer
$150
$150 $150
Apple, Inc.
Vice President, Sales
$100 $100 $100
SAP America
OIND
DCOM
DOTH
DPTY
Dscc
DiND
DCOM
DOTH
DPTY
oscc
SUBTOTAL $ $350 I
'Contributor Codes
IND -Individual
COM - Recipient Committee
(other than PTY or SCC)
OTH - Other (eg., business entity)
PTY - Political Party
FPPC Form 460 (January/OS)
SCC - Small Contributor Committee
FPPC Toll-Free Helpline: 866/ASK·FPPC (866/275-3772)
I
SCHEDULE B - PART 1
Schedule B - Part 1
Loans Received
Type or print in ink.
Amounts may be rounded
to whole dollars.
Statement covers period
from 07/01/2010
CALIFORNIA 460
FORM
SEE INSTRUCTIONS ON REVERSE through
09/30/2010 6 7
Page of _
NAME OF FILER I.ID. NUMBER
NANCY CARLSON FOR CITY COUNCIL 2010 1330148
0'
(b)--­
-
(d) tel
-
(f) (9) (e)
OUTSTANDING
AMOUNT
AMOUNT PAID
OUTSTANDING
INTEREST ORIGINAL CUMULATIVE
BALANCE
RECEIVED THIS
BALANCE AT
PAID THIS AMOUNT OF CONTRIBUTIONS
BEGINNING THIS
OR FORGIVEN
C L O ~ ~ 9 ~ ~ H I S
pFRlon
PERIOD
THIS PERIOD' P RI
PERIOD LOAN TO DATE
o PAID
CALENDAR YEAR
0
$
313.58 _0_,,­
$
313.58
$
313.58
-
o FORGIVEN
RATE
PER ELECTION"
0 I 313.58 I
0 0 08/27/10
5
DATE DUE DATE INCURRED
o PAID
CALENDAR YEAR
0
S
1401.60 _0_% 5 1401.60
5
1715.18
-
RATE
PER ELECTION" o FORGIVEN
0 I 1401.60 I 0 0 08/20/10
-
5
DATE DUE DATE INCURRED
o PAID
CALENDAR YEAR
0
S
200.00 _0_%
S
200.00
5
1915.18
-
RATE
PER ELECTION" o FORGIVEN
0 I 200.00 I 0
-
0 08/04/10
IF AN INDIVIDUAL. ENTER
OCCUPATION AND EMPLOYER
(IF SELF-EMPLOYED. ENTER
NAME OF BUSINESS)
Realtor
Intero Real Estate
Realtor
Intero Real Estate
Realtor
Intero Real Estate
FULL NAME. STREET ADDRESS AND ZIP CODE
OF LENDER
(IF COMMITTEE. AlSOENTER I D NUMBER)
Nancy Carlson
tlilJ IND 0 COM DOTH 0 PTY 0 SCC
tGll IND 0 COM DOTH 0 PTY 0 SCC
Nancy Carlson
tlilJ IND 0 COM DOTH 0 PTY 0 SCC I I I I I DATE DUE I I DATE INCURRED
SUBTOTALS $ $ $ $ I'
(Enlerle)m
SchedlJIAE.L""'3)
Schedule 8 Summary
1915.18
1. Loans received this period .. _ $
(Total Column (b) plus unitemized loans of less than $100.)
o
2. Loans paid or forgiven this period _ $
(Total Column (c) plus loans under $1 00 paid or forgiven.)
(Include loans paid by a third party that are also itemized on Schedule A.)
1915.18
3. Net change this period. (Subtract Line 2 from Line 1.) NET $
(May be a negative number)
Enter the net here and on the Summary Page, Column A, Line 2.
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
'Amounts forgiven or paid by another party also must be reported on Schedule A.
" tf required. FPPC Form 460 (January/OS)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
I
SCHEDULEE
Schedule E
Type or print in ink.
Statement covers period
Amounts may be rounded CALIFORNIA 460
Payments Made
to whole dollars.
from 07/01/2010
FORM
09/30/2010 7 7
Page of through
SEE INSTRUCTIONS ON REVERSE
--_._-_.__ .
NAME OF FILER ~ N U M B E R
NANCY CARLSON FOR CITY COUNCIL 2010 1330148
CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment.
QvlP 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 filinglballot fees PHO phone banks me candidate travel. lodging, and meals
FNO fund raising events POL polling and survey research TRS staff/spouse travel. lodging. and meals
!NO independent expenditure supporting/opposing others (explain)" pas postage. delivery and messenger services TSF transfer between committees of the same candidate/sponsor
LEG legal defense PRO professional services (legal, accounting) VaT voter registration
LIT campaign literature and mailings PRT print ads V\lEB information technology costs (internet, e-mail)
NAME AND ADDRESS OF PAYEE
AMOUNT PAID IIF COMMITTEE. ALSO ENTER J.D. NUMBER) CODE OR DESCRIPTION OF PAYMENT
...
Bank of America VISA Yard signs (Sign Outfitters www.signoutfitters.com)
P.O. Box 301200 CMP 313.58
Los Angeles, CA 90030-1200
Bank of America VISA Business cards, postcards, flyers (Reps
P.O. Box 301200 CMP reps@respweb.com, www.repsweb.com)
1401.60
Los Angeles, CA 90030-1200
* Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL $
Schedule E Summary
1. Itemized payments made this period. (Include all Schedule E subtotals.) $ 1715.18
2. Unitemized payments made this period of under $1 00 , $ 30.61
3. Total interest paid this period on loans. (Enter amount from Schedule B, Part 1, Column (e).) $ _
4. Total payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.) TOTAL $ 1745.79
FPPC Form 460 (January/OS)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)