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
Campaign Statement
Cover Page
Type or print in ink. Date Stamp .. e.
COVER PAGE

(Government Code Sections 84200-84216.5)

Statement covers period Date of election if applicable:
(Month, Day, Year) CITY CL E~"'SI'iI F .~- I
from 07/01/2010

SEE INSTRUCTIONS ON REVERSE through 09/30/2010 11/02/2010 2010 ocr -I 2: I I .

1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4. 2. Type of Statement: I I ".
o Officeholder, Candidate Controlled Committee o Primarily Formed Ballot Measure I;zI Preelection Statement o:.., z "~!FC'~rrl ,\
Quarterly Staler'r11"int
o State Candidate Election Committee Committee o Semi-annual Statement o Special Odd-Year Report
o Recall o Controlled
U Termination Statement o Supplemental Preelection
(AlSO Complere ParT 5) o Sponsored
(Also file a Form 410 Termination) Statement - Attach Form 495
o General Purpose Committee (AlSO Complete Part 6)
o Amendment (Explain below)
o Sponsored \Zl Primarily Formed Candidate/
o Small Contributor Committee Officeholder Committee
o Political Party/Central Committee IAlso Complete Part T}

1.0. NUMBER
3. Committee Information Treasurer(s)
1330148
COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER

NANCY CARLSON FOR CITY COUNCIL 2010 Ted Forsman

MAILING ADDRESS

501 San Felicia Way

STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
981 Thatcher Drive Los Altos CA 94022 650-575-6704
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY

Los Altos CA 94024 650-255-1435 Nancy Carlson

MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX MAILING ADDRESS

981 Thatcher Drive

CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE

Los Altos CA 94024 650-255-1435

OPTIONAL: FAX / E-MAIL ADDRESS OPTIONAL: FAX / E-MAIL ADDRESS

nmcarlsonO 1@yahoo.com 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 ~ J :A:~t~T- ~_~_'~_:T~_~~~
09/27/2010
Executed on
Date
By ~'. __ .Y~_~}J.J9:'¥~ ......<; u •••,._nu. _",.~"__ . .'o __

Executed on
Date By rt
Sigture of Controlling Officeholder. Candidate, State Measure Proponent

Execu1ed on
Dal. By ---------,;S".ig.,.,na::-'u-:re,...o7.fc~o,.,.n"'tro"'lIi.,.,ng:-;Offi=ce:-:h,.,.ol;:;-d.:c:r.'C::-an""d:::ld;::al::-e,-;:S"'ta"',e":'M:::e-as-ure=p-'ro- po:C:n"".n::-,- - - - - - ­
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
OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) BALLOT NO. OR LETTER JURISDICTION o SUPPORT
City Council Member Los Altos
o OPPOSE
RESIDENTIAl/BUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP
Identify the controlling officeholder, candidate, or state measure proponent, if any.
981 Thatcher Drive Los Altos, CA 94024
NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT

Related Committees Not Included in this Statement: List any committees

OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY
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.

COMMITIEE NAME 1.0. NUMBER

7. Primarily Formed Candidate/Officeholder Committee List names of

NAME OF TREASURER CONTROLLED COMMITTEE?
officeholder(s) or candidate(s) for which this committee is primarily formed.
DYES o NO
COMMITTEE ADDRESS STREET ADDRESS (NO P.O. BOX)
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
o SUPPORT
o OPPOSE
CITY STArE ZIP CODE AREA CODE/PHONE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD I
o SUPPORT
o OPPOSE
COMMITTEE NAME '1.0. NUMBER
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
o SUPPORT
o OPPOSE
NAME OF TREASURER CONTROLLED COMMITTEE?

o NO
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
o SUPPORT
DYES
o OPPOSE
COMMITTEE ADDRESS STREET ADDRESS (NO PO. BOX)

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


Campaign Disclosure Statement
Summary Page
SEE INSTRUCTIONS ON REVE':lSE
NAME OF FILER
NANCY CARLSON FOR CITY COUNCIL 2010
Contributions Received
1. Monetary Contributions
2. Loans Received.
3. SUBTOTAL CASH CONTRIBUTIONS
4. Nonmonetary Contributions
5. TOTAL CONTRIBUTIONS RECEIVED
Expenditures Made
6. Payments Made.
7. Loans Made
8. SUBTOTAL CASH PAYMENTS ..
9. Accrued Expenses (Unpaid Bills)
10. Nonmonetary Adjustment
11. TOTAL EXPENDITURES MADE.......
Current Cash Statement
12. Beginning Cash Balance
13. Cash Receipts
14. Miscellaneous Increases to Cash
15. Cash Payments ....
16. ENDING CASH BALANCE ..
If this is a termination statement, Line 16 must be zero.
17. LOAN GUARANTEES RECEiVED
Cash Equivalents and Outstanding Debts
18. Cash Equivalents
19 Outstanding Debts
. Schedule A. Line 3
. . Schedule B. Line 3
. Add Lines 1 + 2
. Schedule C, Line 3
Add Lines 3 + 4
Schedule E. Line 4
. . Schedule H, Line 3
Add Lines 6 + 7
. Schedule F. Line 3
SchedufeC.Line3
Add Lines 8 + 9 + 10
.. Previous Summary Page. Lme 16
. Column A, Line 3 above
__ . Schedule I. Lme 4
Column A. Line 8 above
. Add Lines 12 + 13 + 14. then subtract Line 15
. Schedule B. Part 2
See instructions on reverse
. Add Line 2 + Line 9 in Column B above
Type or print in ink. SUMMARY PAGE
Amounts may be rounded
to whole dollars.
from
Statement covers period
07/01/2010
CALIFORNIA
FORM
460
I through 09/30/2010 I 3 ­ of
Page - - 7 I
ID. NUMBER
1330148
ColumnA ColumnB Calendar Year Summary for Candidates
TOTAL THIS PERIOD CALENDAR YEAR
Running in Both the State Primary and
(FROM ATTACHED SCHEDULES) TOTAl TO DATE
General Elections
$ 750 $
750
1/1 through 6/30 7/1 to Date
1915.18 1915.18
2665.18 2665.18 20. Contributions
$ $ Received $ _ $----­
o o 21. Expenditures
2665.18 2665.18 Made $ _ $
$ $
Expenditure Limit Summary for State
$ 1745.79 $ 1745.79 Candidates
o o
22. Cumulative Expenditures Made'
$ 1745.79 $ 1745.79 (If Subject to Volunbry Expenditure Limit)
o o Date of Election Total 10 Date
o o (mm/dd/yy)
$ 1745.79 $ 1745.79 ------l--l_ _ $----­
$----­
$
o
To calculate Column B, add
2665.18 amounts in Column A to the
corresponding amounts
o from Column B of your last
'Amounts in this section may be different from amounts
reported in Column B.
1745.79 report. Some amounts in
Column A may be negative
$ 919.39 figures that should be
subtracted from previous
period amounts. If this is
the first report being filed
$
o for this calendar year. only
carry over the amounts
from Lines 2. 7. and 9 (if
any).
$ o
$ 1915.18 FPPC Form 460 (January/OS)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Schedule A Type or print in ink. SCHEDULE A
Amounts may be rounded
Monetary Contributions Received to whole dollars.
Statement covers period

from 07/01/2010
CALIFORNIA
FORM
460
through 09/30/2010 Page 4 of 7
SEE INSTRUCTIONS ON REVERSE
NAME OF FILER I.D. NUMBER

NANCY CARLSON FOR CITY COUNCIL 2010 1330148

DATE FULL NAME. STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR

(IFCOMMITIEE.ALSOENTER1.D.NUMBER)

I CONTRIBUTOR
CODE *

IF AN INDIVIDUAL. ENTER
OCCUPATION AND EMPLOYER
AMOUNT
RECEIVED THIS
CUMULATIVE TO DATE
CALENDAR YEAR
PER ELECTION
TO DATE
RECEIVED
(IF SELF·EMPLOYED. ENTER NAME PERIOD (JAN. 1 - DEC. 31) (IF REQUIRED)

OF BUSINESS)

hZllNO
08/26/2010 oCOM Retired $50 $50 $50
DOTH
oPTY
osee
~INO
oeOM Self employed
08/24/2010 $50 $50 $50
DOTH NCL Associates
oPTY
osee
\;ZJ INO
08/26/2010
OCOM General Manager $100 $100 $100
DOTH Monumental Ventures
oPTY
OSCC

{llINO
08/30/2010 oeOM CFO $100 $100 $100
DOTH Coast RV
oPTY
osee

blIlNO
John and Dani Thompson oeOM Vice President
09/14/2010 $100 $100 $100
DOTH Intero Real Estate
OPTY
osee

Schedule A Summary -Cuntribulor Codes

1. Amount received this period - itemized monetary contributions. $750 IND-Individual

COM - Recipient Committee
(Include all Schedule A subtotals.) $ _ (olher than PTY or SeC)
OTH - Other (e.g., business entity)
2. Amount received this period - unitemized monetary contributions of less than $100 $ $0 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)
Monetary Contributions Received Amounts may be rounded
to whole dolla rs.
from
Statement covers period

07/01/2010
CALIFORNIA
FORM
460
through 09/30/2010 Page 5 of 7
NAME OF FILER I.D.NUMBER

NANCY CARLSON FOR CITY COUNCIL 2010 1330148

DATE FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR

(IF COMMITIEE. ALSO ENTER I.D. NUMBERj
I CONTRIBUTOR
CODE *
IF AN INDIVIDUAL, ENTER
OCCUPATION AND EMPLOYER
AMOUNT
RECEIVED THIS
CUMULATIVE TO DATE
CALENDAR YEAR
PER ELECTION
TO DATE
RECEIVED (IF SELF·EMPLOYED. ENTER NAME PERIOD (JAN. 1 • DEC 31) (IF REQUIRED)
OF BUSINESS)

IllIND
William and Maria Lonergan OCOM Software Sales
09/20/2010 OfferPal, Media $100 $100 $100
DOTH
DPTY
DSCC
IllIND
Product Designer
09/21/2010 OCOM $150 $150 $150
DOTH Apple, Inc.
DPTY
Dscc
IllIND
DCOM
Vice President, Sales
08/3012010 $100 $100 $100
DOTH SAP America
DPTY
Dscc
OIND
DCOM
DOTH
DPTY
Dscc
DiND
DCOM
DOTH
DPTY
oscc
SUBTOTAL $ $350 I 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)
 SCHEDULE B - PART 1
Type or print in ink.
Schedule B - Part 1
Loans Received
Amounts may be rounded
to whole dollars.
Statement covers period

from 07/01/2010
CALIFORNIA
FORM
460
09/30/2010 Page 6 of 7 _
SEE INSTRUCTIONS ON REVERSE through
NAME OF FILER I.ID. NUMBER

NANCY CARLSON FOR CITY COUNCIL 2010 1330148

- -

FULL NAME. STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL. ENTER 0'
OUTSTANDING
(b)--­
AMOUNT
(e)
AMOUNT PAID
(d)
OUTSTANDING
tel
INTEREST
(f)
ORIGINAL
(9)
CUMULATIVE
OF LENDER OCCUPATION AND EMPLOYER BALANCE BALANCE AT
RECEIVED THIS OR FORGIVEN PAID THIS AMOUNT OF CONTRIBUTIONS
(IF SELF-EMPLOYED. ENTER
(IF COMMITTEE. AlSO ENTER I D NUMBER)
NAME OF BUSINESS)
BEGINNING THIS
PERIOD THIS PERIOD'
CLO~~ 9~~HIS PERIOD LOAN TO DATE
pFRlon P RI

Nancy Carlson Realtor

o PAID CALENDAR YEAR

313.58 313.58
Intero Real Estate -0 $ _0_,,­ $
313.58 $

o FORGIVEN RATE
PER ELECTION"

0 I 313.58 I 0 5
0 08/27/10
tGll IND 0 COM DOTH 0 PTY 0 SCC DATE DUE DATE INCURRED

Nancy Carlson Realtor

o PAID CALENDAR YEAR

0 1401.60 _0_% 5 1401.60 1715.18

Intero Real Estate - S 5

o FORGIVEN RATE
PER ELECTION"

0 I 1401.60 I 0
- 5
0 08/20/10
tlilJ IND 0 COM DOTH 0 PTY 0 SCC DATE DUE DATE INCURRED

Realtor
o PAID CALENDAR YEAR

200.00 1915.18
Intero Real Estate -0 S
200.00 _0_% S 5
o FORGIVEN RATE
PER ELECTION"

0 I 200.00 I 0 - 0 08/04/10
tlilJ IND 0 COM DOTH 0 PTY 0 SCC I I I I I DATE DUE I I DATE INCURRED

SUBTOTALS $ $ $ $ I' I
(Enlerle)m
Schedule 8 Summary SchedlJIAE.L""'3)

1915.18
1. Loans received this period .. _ $
(Total Column (b) plus unitemized loans of less than $100.) tContributor Codes

2. Loans paid or forgiven this period _ $ o IND -Individual

COM - Recipient Committee
(Total Column (c) plus loans under $1 00 paid or forgiven.) (other than PTY or SCC)
OTH - Other (e.g .. business entity)
(Include loans paid by a third party that are also itemized on Schedule A.)
PTY - Political Party
1915.18 SCC - Small Contributor Committee
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.
'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)
 SCHEDULEE
Schedule E
Payments Made
Type or print in ink.
Amounts may be rounded
to whole dollars.
Statement covers period
CALIFORNIA
FORM
460
from 07/01/2010

09/30/2010 Page
7 of
7
SEE INSTRUCTIONS ON REVERSE through
--_._-_. __ .
NAME OF FILER ~NUMBER

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

IIF COMMITTEE. ALSO ENTER J.D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNT PAID
...

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)