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Section I
CAMPAIGN FINANCIAL DISCLOSURE REPORT
SUMMARY PAGE
(Please Print or Type)
C-2
Rev. 10/07
Name of Candidate or Political Committee andpChairper on
02.90 N
Office Sought (if candidate) '
Cl C6vN
Seat(if any)
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Mailing AddressHome
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or one
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Mailing Address
City an Zip
ome one
Work Phone
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Change of address for: Candidate or Political Committee ❑ Political Treasurer
Section II TYPE OF REPORT
This filing is an: ❑ Original ❑ Amendment
This report is for the period from 1 / 01 L-11 through Q 131 /)9
❑ October 10 Pre -General Report
® Annual Report
Is this a Termination Report: ❑ Yes
❑ 7 Day Pre -General Report
❑ 30 Day Post -General Report
Section III STATEMENT OF NO CONTRIBUTIONS OR EXPENDITURES
Directions: If you had no contributions or expenditures during this reporting period, check the box next to the statement below and sign this report.
Be sure to carry forward the appropriate "Calendar Year to Date" figures in Column II, Section IV.
W
❑ I hereby certify that I have received no contributions and have made no expenditures during this reporting period.
SUMMARY
To reach your Calendar Year to Date figure: Add this report's Column I
figures to the Column II figures of your previous report (except on line 6).
Line 1: Cash on Hand January 1, This Calendar Year'
Line 2: Enter Beginning Cash Balance"
Line 3: Total Contributions (Enter amount from line 5, page 2)
Line 4: Subtotal (Add lines 1, 2 and 3)
Line 5: Total Expenditures (Enter amount from line 11, page 2)
Line 6: Enter Ending Cash Balance (Subtract line 5 from line 4)
Line 7: Outstanding Debt to Date (Enter amount from line 18, page 2)
COLUMN I
This Period
COLUMN II
Calendar Year
to Date
$ .ag
$ xxxxxx
$
$ 4IS6 •ay
$ 00
$400.9
'This same figure should be entered on line 1 of all reports filed this calendar year.
"This is the figure on line 6 of the last Campaign Financial Disclosure Report filed. If this is your first report, this amount is 0.
Note: The closing cash balance for the current reporting period appears on the next report as the beginning cash on hand.
Section V
I, A 86400 hereby certify that the information in this
Name of Political Treasurer
report is a true, complete and correct Campaign Financial Disclosure Report as required by law.
Page 1
rreasurer
DETAILED SUMMARY
Name of Candidate or Committee:
Loans, Credit Cards and Debt $-
- —-------------
Outstanding Balance from previous reporting period + $
13 New Loans received during this reporting period
(Total of all New Loan amounts plus Accrued Interest from Schedule D sheets) + $
14 New Credit Card and Debt incurred this reporting period
(Total of all New Incurred Debt amounts from Schedule E sheets) + $
15 Subtotal = $ 0.00
16 Repayments of Loans made during this reporting period
(Total of all Loan Repayment amounts from Schedule D sheets) $
- - - _ _. - -_-- - -
17 Repayments of Credit Card and Debt this reporting period
(Total of all Debt Repayment amounts from Schedule E sheets) $
1g Total Outstanding Balance at close of this period (Transfer this figure to page 1, Section IV, Line 7) $ 0.00
Page 2
SCHEDULE A age o
ITEMIZED CONTRIBUTIONS 1
of more than Fifty Dollars ($50.00) this period
Name of Candidate or Committee:
Date Received
Full Name, Mailing Address and Zip Code of Contributor
Cash or Check
1.
$
❑ General
Calendar Year -To -Date
2.
❑ General
Calendar Year -To -Date
3.
❑ General
Calendar Year -To -Date
4.
❑ General
Calendar Year -To -Date
5.
❑ General
Calendar Year -To -Date
I I
6.
$
$
❑ General
Calendar Year -To -Date
7.
$
❑ General
Calendar Year -To -Date
8.
❑ General
Calendar Year -To -Dale
9.
❑ General
Calendar Year -To -Date
10.
❑ General
Calendar Year -To -Date
Total This Page:
$ 0.00
Transfer the combined total of all Schedule A pages to the Detailed Summary on page 2 line 2.
Dale Spent
Full Name, Mailing Address and Zip Code of Recipient
SCHEDULE B age o
ITEMIZED EXPENDITURES
Twenty -Five Dollars ($25.00) or more this period
Name of Candidate or Committee:
Ll Gv"v,
Purpose Codes
$
A
All Travel Expenses (Airfare, Fuel, Lodging & Mileage) N
Newspaper & Other Periodical Advertising
B
Broadcast Advertising (Radio, TV & Internet) 0
Other Advertising (Yard Signs, Buttons, etc.)
C
Contributions to Candidates & PAC's
P
Postage
D
Donations & Gifts
S
Surveys & Polls
E
Event Expenses
T
Tickets (Events)
F
Food & Refreshments
U
Utilities
G
General Operational Expenses
W
Wages, Salaries, Benefits & Bonuses
L
Literature, Brochures, Printing
Y
Petition Circulators
M
Management Services
Z
Preparation & Production of Advertising
Dale Spent
Full Name, Mailing Address and Zip Code of Recipient
Purpose Code
Cash or Check
Ll Gv"v,
$
2.
3.
4.
I I
$
5.
6.
$
7.
——
$
8.
9.
10.
Total This Page:
w (JU
Transfer the combined total of all Schedule B pages to the Detailed Summary on page 2 line 7.