REPORT OF CONTRIBUTIONS AND EXPENDITURES ( , C.R.S.)

Transcription

1 Retumto: Beth A. Hedberg, MMC City Clerk City ofedgewater 2401 Sheridan Boulevard Edgewater, CO Fax: REPORT OF CONTRBUTONS AND EXPENDTURES ( , C.R.S.) Space Below For Office Use Only Full Name of CommitteelPerson: Address of CommitteelPerson: City, State & Zip Code: Committee Type: Name and Address of Financial nstitution Type?port SOS D NUMBER (state and county committees): L--=~ ~~~~~~~ ~ ~gularly Scheduled Flng. D Amended Filing. This amends previous report filed on (date) Submit changes or new information ONLY D Tennination ReJ>Ort. (fennination Reports MUST Have a Monetary Balance ofzero in Line 5) D Check this box ifthis Report Contains Electioneering s nfonnation Reporting Period Covered: Alav..3 ~ ()/? Date Declared Total Spending (ifapplicable) /1""'1. : [Art XXVll, Sec. 4(\)]. _.,( '2.A:::::' Totals Detailed Summary Page Funds on Hand at the Beginning ofreporting Period (monetary only) /Q{).1J3 2 Total Monetary Contributions (line 11) 0 3 Total ofmonetary Contributions & Beginning Amount (line 1 + line 2) J 20. g'~ 4 Total Monetary Expenditures (line 19) 11~.Cl2 5 Funds on Hand at the End of R~rting Period (monetary) (line 3 -line 4) Xl/ The appropriate officer shall impose a penalty of 50 per day for each day that a report is filed late. rart. XXVn Sec. 10(2)(a)1 Authorization (Must be completed by either the Registered Agent OR the Candidate): hereby certify and declare, under penalty ofperjury, that to the best ofmy knowledge or beliefall contributions received during this reporting period, including any contributions received in the form ofmembership dues transferred by a membership organization, are from permissible sources. noud- ~ Print Registered Agent's Name: ----0;;::;7~<...U,~.,;--...1}~"-=---=----.:...lo. '~ Registered Agent's Signature: --".u..~-;&~_= Date: Print Candidate Name: _~~~~~L--~~~~~ Candidates Signature: -----A~~~~~~===== Date:,Pu. 7 ~C>i'- Colorado Secretary ofstate Form Rev

2 DETALED SUMMARY Full Name of CommitteelPerson: ----lg~qv"--'v'-'--'--'fr~~=ij,:--lgl Jr' 't;.""'-:AC:f4~~~Ji=e.c Current Reporting Period: r-- N - -v-.-3-z-() ,1 Through L...,Q:...t:..Si.e""'c...L.?_g.=O~/Z:......J Q Funds on band at the beginning of reporting period (Monetary Only) /cj().83-6 temized Contributions 20 or More [C.R.S (1)(a)) (Please list on Schedule "A") r 7 Total of Non-temized Contributions (Contributions ofs9.99 and Less).-- 8 Loans Received (plea<>e list on Schedule "C") - 9 Total of Other Receipts (nterest. Dividends, etc.) - 10 Returned Expenditures (from recipient) (Plea<>e list on Schedule "D") -" 11 Total Monetary Contributions (Total oflines 6 through 10) 12 Total Non-Monetary Contributions (From Statement ofnon-monetary Contributions) Total Contributions 0 (Line + line 12) 14 temized Expenditures 20 or More [C.R.S (1)(a)] Jo~i2 (Please list on Schedule "B") 15 Total of Non-temized Expenditures (Expenditures ofs19.99 or Less) Loan Repayments Made 16 (Please list on Schedule "C") 0 17 Returned Contributions lto donor) (Plea<>e list on Schedule "D") D -to 18 Total Coordinated Non-Monetary Expenditures (Candidate/Candidate Committee & Political Parties only) ~ Total Monetary Expenditures 19 ~.L1:2 (Total oflines 14 through 17) Total Spending 20 [la.4~ (Line 18 + line 19) Colorado Secretary of State Form Rev. 12JOO

3 Schedule A - temized Contributions Statement (20 or more) [C.R.S (l)(a)] Full Name of CommitteelPerson: WARNNG: Please read the instruction page for Schedule "A" before completing PLEASE PRlNTf'YPE 1. Date Accepted 1 2. Contribution Amt. 1 i 3. Aggregate Amt...., 8. Employer (ifapplicable, mandatory): Electioneering 9. Occupation (if applicable, mmlgatoa): 1. Date Acc,lted 12. Contribution Amt. 3. Agmgate Amt Employer (if applicable, mandatory): Electioneering 9. Occupation (if applicable, Wlmg8t2a): 1. Date Accepted 1 2. ContributiQn Amt. 3. Agg[eggte Am Employer (ifapplicable, mlmdatory): Electioneering 9. Occupation (if applicable, mandatoa): 1. Date Accepted 1 2. ContributiQn Amt Agll'egate Am Employer (ifapplicable, mml<atory): Electioneering 9. Occupation (if applicable, mandtoa): For contribution limits within a committee's election cycle or contribution cycle, please refer to the following Colorado Constitutional cites: Candidate Committee Art. XXVll, Sec. 2(6); Political Party Art. XXVl, Sec. 3(3); Political Committee Art, XXV, Sec 3(5); Small Donor Committee Art. XXV, Sec. 2(14). Colorado Secretary of State Form Rev. 12/09

4 Schedule B - temized Expenditures Statement (20 or more) ( (1)(a), C.R.S.] Full Name of Committee/Person: ~ 120 vvjr8(; ~( t:~ewk PLEASE PRlNTrrYPE 1. Date Exm:nded / / ler/,.=? ~7. l./:l 1. Date Ex~nded t~t Name: WivtJ, Been Fcv: 535D W :J.5 fk Ave ktf'c)t&..l ~, CO 80,)14' 7. Purpose ofexpenditure: 6l1l-l :&l C~fO"fF &uudo Check box if Electioneering 4. Name: {;; ~le, Ak2()fds 5. Addre: /~~ :::::~ ~ 6. City/StatelZiP:~Z =A :;'-i5 7. Purpose ofexpenditure: We,k.5lb pctl ~o."-"bl:f Electioneering 1. Date Ex~nded 1. Date Ex~nded 1. 12~te Ex~nded 4. Name: 7. Purpose ofexpenditure: Electioneering 4. Name: 7. Purpose of Expenditure: Electioneering 4. Name: 7. Purpose of Expenditure: Electioneering Colomdo Secretary of State Form Rev

5 Schedule C - Loans Full Name of Committee/Person: --~~ ~-- LOANS - Loans Owed by the Committee (Use a separate schedule for each loan. This form is for line item 8 and 16 ofthe Detailed Summary Report.) [No infonnation copied from such reports shall be sold or used by any person for the purpose ofsoliciting contributions or for any commercial purpose. [Art. XXV. Sec. 9(e)] Notwithstanding any other section ofthis article to the contrary, a candidate's candidate committee may receive a loan from a fnancial institution organized under state or federal law if the loan bears the usual and customary interest rate, is made on a basis that assures repayment, is evidenced by a written instrument, and is subject to a due date or amortization schedule [Art. XXV, Sec. 3(8)] LOAN SOURCE Name (Last, First or nstitution): Adme~: City/State/Zip: Original Amount of Loan: nterest Rate: Total ofall Loans This Reporting Loan Amount Received This Reporting Period: Period: =---:-:-,..,, ::: (Place on line 8 of Detailed Summary Report) Principal Amount Paid This Reporting Period: nterest Amount Paid This Reporting Period: Amount Repaid This Reporting Period: _---: Total Repayments Made: ---:-:----=~ (Amount Repaid is sum of Principal & nterest entered on Detail Summary) Outstanding Balance: (Sum of Schedule C pages, Place on line 16 of Detailed Summary) TERMS OF LOAN: Date Loan Received Due Date for Final Payment LST ALL ENDORSERS OR GUARANTORS OF THS LOAN Full Name Address t Cityt State t Zip Amount Guaranteed Colorado Secretary of State Form Rev. 12/09 t t t

6 Full Name of CommitteePerson: Schedule D - Returned Contributions & Expenditures Returned Contributions (Previously reported on Schedule A - Contributions accepted and then returned to donors) t ~ ( ~ r PLEASE PRNTtrYPE 1. Date AcceQted 1. Date AcceQted 4. Name (Last. First): 7. Purpose: 4. Name (Last. First): 6. City/State/Zip; 7. Purpose: Returned Expenditures (Previously reported on Schedule B - Expenditures returned or refunded to the conunittee) PLEASE PRNTtrYPE 1. Date EXQended 4. Name (Last. First): 7. Comment (Optional); 1. Date E~nded 7. Comment (Optional): Colorado Secretary of State Fonn Rev. 12/09

7 Statement of Non-Monetary Contributions [Art. XXV, Sec. 2(5)(a)()(lll) & Sec. 5(3) & (1), C.R.S.] Full Name of Committee/Person: PLEASE PRlNTffYPE 1. Date Provided 2. Fair Market Value 3. Aggregate Amt. Electioneering 8. Employer (if applicable, mandatory): 9. Occupation (if applicable, mandatory): 10. D Check box if Coordinated with a Candidate/Candidate Committee or Political Party. 1. Date Provided 2. Fair Market Value 3. Aggregate Amt. Electioneering 1. Date Provided 2. Fair Market Value 3. Aggregate Amt. Electioneering 8. Employer (if applicable, mandatory): 9. Occupation (if applicable, mandatory): 10. D Check box if Coordinated with a Candidate/Candidate Committee or Political Party. 8. Employer (if applicable, mandatory): 9. Occupation (if applicable, mandatory): 10. D Check box if Coordinated with a Candidate/Candidate Committee or Political Party. Note: fcoordinated, then contribution must also be reported as a non-monetary expenditure on Detailed Summary. Art. XXVll, Sec. 2(9) states: "... Expenditures that are controlled by or coordinated with a candidate or candidate's agent are deemed to be both contributions by the maker of the expenditures, and expenditures by the candidate committee." f ~ Colorado Secretary of State Form Rev. 12/09, f i