City Clerk's Office Lakewood Civic Center 480 S Allison Parkway Lakewood, CO 80226-3127 Phone: 303-987-7080 Fax: 303-987-7088 TDD: 303-987-7057 REPORT OF CONTRIBUTIONS AND EXPENDITURES Full Name of Committee/Person Address of Committee/Person (as shown on registration) Roybal for Lakewood's Future 6445 W. Nevada Place City, State & Zip Code Lakewood, CO 80226 Committee Type Name and Address of Financial Institution Candidate Committee Solera National Bank, 319 South Sheridan Blvd., Lakewood, CO 80226 Type of Report: Regularly Scheduled Filing Amended Filing Termination Report This amends previous report filed on (date) Submit changes or new information ONLY (Termination Reports MUST have a monetary balance of zero in Line E) Report Period Covered: April 7, 2015 Through August 26, 2015 Loans - Outstanding Balance: A Funds on Hand at the Beginning of Reporting Period (Includes Committee Funds Transferred) Totals Detailed Summary Page $0.00 B Total Monetary Contributions (line 3) $2,325.00 C Total Contributions & Beginning (line A + line B) $2,325.00 D Total Expenditures (line 7) $881.00 E Funds on Hand at the End of Reporting Period (line C - line D) $1,444.00 Print Registered Agent's Name: -OR- Print Candidate Name: Pedro Roybal I understand that contributions and expenditures are governed by Chapter 2.54 Campaign and Political Finance in Municipal Elections of the Lakewood Municipal Code. I further certify that I have read and understand the provisions of Chapter 2.54 Campaign and Political Finance in Municipal Elections of the Lakewood Municipal Code. The City Clerk shall impose a penalty for each day a report is filed late per Chapter 2.54.050 (C) Campaign and Political Finance in Municipal Elections of the Lakewood Municipal Code and Rule #13 of the City Clerk Rules and Regulations. By submitting this form, I hereby certify and declare, under penalty of perjury, that to the best of my knowledge or belief all contributions received during this reporting period are from permissible sources. I agree my electronic signature is the legal equivalent of my manual signature that is on file at the City Clerk's Office.
DETAILED SUMMARY Full Name of Committee/Person: Roybal for Lakewood's Future Report Period Covered: April 7, 2015 Through August 26, 2015 Funds on hand at the beginning of reporting period (Includes Candidate Contribution Funds Transferred) $0.00 1 Itemized Contributions more than $20.00 $2,325.00 2 Total of Non-Itemized Contributions (Contributions of $20.00 or less) $0.00 3 Total Monetary Contributions (Total of lines 1 & 2) $2,325.00 4 Total Non-Monetary Contributions $1,746.00 5 Itemized Expenditures more than $20.00 $881.00 6 Total of Non-Itemized Expenditures (Expenditures of $20.00 or less) $0.00 7 Total Expenditures (Total of lines 5 & 6) $881.00
ITEMIZED CONTRIBUTIONS STATEMENT (more than $20.00) Full Name of Committee/Person: Roybal for Lakewood's Future Name: (Last, First or Business)Dalton, John 1 Address: 400 South Lamar Street Apr 7, 2015 $20.00 Name: (Last, First or Business)Fern, David 2 Address: 10473 West Arkansas Drive City/State/Zip: Lakewood, CO 80232 Apr 7, 2015 $30.00 Name: (Last, First or Business)Gergen, Gary 3 Address: 1863 South Reed Street City/State/Zip: Lakewood, CO 80232 Apr 7, 2015 $20.00
Name: (Last, First or Business)Runkle, David 4 Address: 1315 South Fenton Street City/State/Zip: Lakewood, CO 80232 Apr 27, 2015 $25.00 Name: (Last, First or Business)Howard, Glenn 5 Address: 401 South Lamar Street Apr 27, 2015 $25.00 Name: (Last, First or Business)Trujillo, Joanne 6 Address: 391 South Newland St. Aug 27, 2015 $25.00
Name: (Last, First or Business)Wiechman, David 7 Address: 722 South Beech Street City/State/Zip: Lakewood, CO 80228 Apr 27, 2015 City of Lakewood $200.00 City Council Member Name: (Last, First or Business)Johnson, Walter 8 Address: 675 Estes Street City/State/Zip: Lakewood, CO 80215 Apr 27, 2015 $100.00 Retired Name: (Last, First or Business)Armstrong, William 9 Address: 8787 West Alameda Ave. Apr 27, 2015 Colorado Christian University $250.00 President
Name: (Last, First or Business)Burris, Lynn 10 Address: 511 South Marshall Street Apr 27, 2015 $25.00 Name: (Last, First or Business)Oleson, Charles 11 Address: 5852 West Pacific Circle City/State/Zip: Lakewood, CO 80227 Apr 27, 2015 $100.00 Retired Name: (Last, First or Business)Frank, Richard 12 Address: 301 South Otis May 26, 2015 $20.00
Name: (Last, First or Business)Hageman, Jerome 13 Address: 1241 South Marshall Street May 26, 2015 $25.00 Name: (Last, First or Business)Kolker, Louis 14 Address: 437 South Quay Street May 26, 2015 $50.00 Name: (Last, First or Business)Rodriguez, Daniel 15 Address: 7265 W. Center Ave., #307 Jun 26, 2015 $30.00
Name: (Last, First or Business)Carpenter, Mel 16 Address: 6405 W. Nevada Place Jun 26, 2015 $300.00 Retired Name: (Last, First or Business)Risley, George 17 Address: 10469 W. Exposition Dr. Jun 26, 2015 $35.00 Name: (Last, First or Business)Lobato, Charlotte 18 Address: 3050 South Golden Way City/State/Zip: Denver, CO 80227 Jun 26, 2015 $25.00
Name: (Last, First or Business)Howard, Shirley 19 Address: 401 South Lamar Street Jun 26, 2015 $50.00 Name: (Last, First or Business)Trujillo, David 20 Address: 2901 W. 34th Ave. City/State/Zip: Denver, CO 80211 Jun 26, 2015 New Image Remodling $100.00 Business Owner Name: (Last, First or Business)Le, Diane 21 Address: 7735 Turner Drive City/State/Zip: Denver, CO 80221 Jul 20, 2015 $50.00
Name: (Last, First or Business)Otton, James and Sue 22 Address: 1868 South Beech Street City/State/Zip: Lakewood, CO 80228 Jul 20, 2015 $100.00 Retired Name: (Last, First or Business)De La Garza, John 23 Address: 13829 W. Amherst Way City/State/Zip: Lakewood, CO 80228 Jul 20, 2015 Jefferson County Public Schools $120.00 Administrator Name: (Last, First or Business)Lynch, Daniel 24 Address: 2217 South Flower Court Jul 20, 2015 $100.00 Retired
Name: (Last, First or Business)Ash, Rick 25 Address: 400 South Ingalls Street Aug 4, 2015 self-employed $500.00 truck driver TOTAL: $2,325.00
STATEMENT OF NON-MONETARY CONTRIBUTIONS Full Name of Committee/Person: Roybal for Lakewood's Future Name: (Last, First or Business)Wiechman, David 1 Address: 722 South Beech Street City/State/Zip: Lakewood, CO 80228 Jun 8, 2015 Description: Banners City of Lakewood $258.00 Fair Market Value City Council Member Name: (Last, First or Business)Wiechman, David 2 Address: 722 South Beech Street City/State/Zip: Lakewood, CO 80228 Jul 16, 2015 Description: Yard Signs City of Lakewood $288.00 Fair Market Value City Council Member Name: (Last, First or Business) Vela, Debra 3 Address: 5285 W Louisiana Ave City/State/Zip: Lakewood, CO May 1, 2015 Description: 6-month office space self-employed $1,200.00 Fair Market Value business owner TOTAL: $1,746.00
ITEMIZED EXPENDITURES STATEMENT (more than $20.00) Full Name of Committee/Person: Roybal for Lakewood's Future Name: (Last, First or Business) Zenith Star Web Site Design 1 Mar 1, 2015 Date of Expense Address: 1505 South Norfolk Street City/State/Zip: Lakewood, CO 80017 Purpose of Expenditure: Web Site maintenance $600.00 Name: (Last, First or Business) Printograph Inc. 2 Jun 16, 2015 Date of Expense Address: 7651 N. San Fernando Road City/State/Zip: Burbank, CA 91505 Purpose of Expenditure: Palm Cards $235.00 Name: (Last, First or Business) Guru Graphics 3 Jun 20, 2015 Date of Expense Address: 4800 Colorado Blvd. City/State/Zip: Denver, CO 80216 Purpose of Expenditure: Banners $46.00 TOTAL: $881.00
LOANS Full Name of Committee/Person: Roybal for Lakewood's Future LOAN SOURCE: Name: (Last, First or Institution) Address: 1 City/State/Zip: Original Loan : Loan Received This Reporting Period: Repaid This Reporting Period: Loan Outstanding Balance:
CANDIDATE COMMITTEE FUNDS TRANSFER FORM This form is used by candidate committees established by the same committee for a different public office intending to transfer existing funds from an existing committee as defined by the Lakewood Municipal Code. FROM Full Name of Committee: Address (physical): Mailing Address (if different from above): Phone Number: Fax Number: Email Address: TOTAL AMOUNT OF TRANSFER: TO Full Name of Committee: Address (physical): Mailing Address (if different from above): Phone Number: Fax Number: Email Address: I understand that campaign finance activities are governed by Chapter 2.54 Campaign and Political Finance in Municipal Elections of the Lakewood Municipal Code and the Lakewood City Clerk Rules and Regulations regarding campaign finance. I further certify that I have read and understand the provisions of Chapter 2.54 Campaign and Political Finance in Municipal Elections of the Lakewood Municipal Code and the Lakewood City Clerk Rules and Regulations regarding campaign finance. By submitting this form, you are signing this Candidate Affidavit electronically and certifying the above information to be true and correct, to the best of your knowledge. You agree your electronic signature is the legal equivalent of your manual signature