State of Georgia Campaign Contribution Disclosure Report

Transcription

1 1. Report Type (Select One) jl Orgnal Report O Amended Report Amendment #. Flng s beng made on behalf of (Select One): [^Canddate or Publc Offcal.. A J s*>,,, /) jj Offce Sought or Held: ''^ W^^*/ /JfaZA^f (Include counv, muncpalty, dstrct, post or judcal crcut) Commttee Name: ~~ Report of Organzaton or Person Other than Canddate's Campagn Commttee. Identfyng and Contact Informaton Flng offce use only Use Earler of Post Mark or Hand Delvered Date O. Full Name of Canddate or Non-Canddate Campagn Co/ L and / or Contact Phone Number (We wll understand the release of [hs nformaton as permss Zp Code () If a Canddate or Publc Offcal, s there a campagn commttee {one or more persons) to make campagn transactons, keep the fnancal records of the campagn, or fle the reports? Q Yes [ffno () If so, s the commttee regstered wth the State Ethcs Commsson? Q Yes PI No () If so, complete the followng: _. Perod for whch you are Reportng Name of Charperson and/ or Tre My Non Electon Year j June 0, QDec. 1, the year n whch he electon occurs such lmds are expended as provded n the Art who receve contrbutons lo retre debt ncurred, debts are satsfed (December 1 flms only) My Electon Year n March 1. D June 0, Q September 0, Q October, [TjDeeember 1f»* ) /^ Run-Off s (Report requred only f you are n a Run-Off Electon! f~ days before Prmary Run-Off, f~ days before General Run-Off, ^ days before Specal Prmary Run-Off, [^] days before Specal Run-Off, Specal Electons D 1 days before Specal Prmary, n 1 days before Specal, DDec. 1, Verfcaton by Oath or Affrmaton State of Georaa, <l>fttl yj& County of t _*, beng duly sworn (affrm), depose and that the nformaton n ths report form s complete, true, and correct. Fu ther, I affrm that the contents n are the same as the contents n the electronc flng submtted, f also ele roncally fled. ay s report Muscoqee Sworn to and subscrbed before me on, 0 Sgnature of Notary Publc a.ysfenarure of Canddate ^ My Commsson expres Any person.ho knowngly ft* to comply.th or who knowngly vda.es any of the

2 REV 0/008 a b c d Summary Report CONTRIBUTIONS RECEIVED l have no contrbutons to report. g I have the followng contrbutons, ncludng Common Source, to report: A. Ifths s the frst tme to fle a dsclosure report for the current offce sought. ENTER 0 n both columns (one tme onlv); or B. Ifths s the frst report of ths Reportng Cycle*. ENTER 0 n the n-knd column and lst anv net balance on hand brought forward from the prevous reportng cvcle n the cash amount column (Lne 1 of prevous report, or total funds left over at year end of prevous cycle); or C. Ifths flng s the second or subsequent flnsz of ths Reoortn Cvcle, lst totals from Lne of prevous report n both the n-knd and cash amount columns. Total amount of all temzed contrbutons receved n ths reportng perod whch are sted on the "Itemzed Contrbutons" page. All loans receved ths reportng perod. nterest earned on campagn account ths reportng perod. Total amount of nvestments sold ths reportng perod. Total amount of cash dvdends and nterest pad out ths reportng perod. Total amount of all separate contrbutons of less than $ receved n ths reportng perod and not lsted on the "Itemzed Contrbutons" page. "Common Source" contrbutons must be aggregated on the "Itemzed Contrbutons" page. Total contrbutons reported ths perod. (Lne + a + b + c + d + ) Total contrbutons to date. Total to be carred forward to next report >f ths reportng cycle*. (Lne + ) EXPENDITURES MADE «,^ B I have no expendtures to report. Q I have the followna expendtures to report: Tota expendtures made and reported pror to ths reportng perod. Ifths s the A. Frst report of ths Reportng Cycle*, ENTER 0. B. Second or subsequent flns ENTER Lne 1 of prevous report. Total amount of all temzed expendtures made n ths reportng perod whch are sted on the "Itemzed Expendtures" page. Total amount of all separate expendtures of less than $ that were made n ths reportng perod and not lsted on the "Itemzed Expendtures" page. Total expendtures reported ths perod. (Lne 9 +10) Total expendtures to date. Total to he carred forward to next report of ths reportng cycle*. (Lne 8+ I!) INVESTMENTS Total value of nvestments held at the begnnng of ths reportng perod. Total value of nvestments held at the end of ths reportng perod. Net balance on hand. (Lne ) * O.C.G.A. 1--(b)(l)J>)() A reportng cycle shall commence on January 1 of the year n conclude; (I) At the expraton of the term of offce f such canddate s elected and does not seek reelect (II) On December 1 of the year n whch such electon was held f such canddate s (III) If such canddate s successful and seeks reelecton or seeks electon to some other offce th' begns. Publc Offcer/Canddate/Non-Canddate Commttee Name In-Knd Estmated Value In-Knd Estmated Value Cash Cash

3 Electon Cycle*: Outstandng Indebtedness Outstandng ndebtedness at the begnnng of ths reportng perod. Electon YeanS^P/^ Loans receved ths reportng perod. Deferred payment of expenses ths reportng perod Payments made on loans ths reportng perod. Credts receved on loans ths reportng perod. Payments ths reportng perod on prevously deferred expenses. Total ndebtedness at the close of ths reportng perod. (Lne ) Electon Cycle*: Outstandng ndebtedness at the begnnng of ths reportng perod. Electon Year: "t> f O Loans receved ths reportng perod. Deferred payment of expenses ths reportng perod Payments made on loans ths reportng perod. Credts receved on loans ths reportng perod. Payments ths reportng perod on prevously deferred expenses. Total ndebtedness at the close of ths reportng perod. (Lne ) Electon Cycle*: Electon Year: <=^{? / > Outstandng ndebtedness at the begnnng of ths reportng perod. Loans receved ths reportng perod. Deferred payment of expenses ths reportng perod Payments made on loans ths reportng perod. Credts receved on loans ths reportng perod. Payments ths reportng perod on prevously deferred expenses. Total ndebtedness at the close of ths reportng perod. (Lne ) * Electon Cycle (Prmary, General, Specal, Specal Prmary, Run-Off Prmary, Run-Off General, Run-Off Specal, Run-Off Specal Prmary) Publc Offcer/Canddate/Non-Canddate Commttee Name _

4 SEC FORM CCDR REV /008 Itemzed Contrbutons Must lst contrbutons receved by a sngle contrbutor for whch the aggregate total s $ or more Note: Loans are no longer reported n ''Itemzed Contrbutons" secton. See Loan Reportng secton below. Full Name of Contrbutor (Afflaton of Commttee f any) Contrbutor Receved Date Contrbuton Type* Occupaton & Employer Electon Cycle** Cash In-Knd Contrbutons Estmated Value Descrpton $0,00 Itemzed Contrbutons Page Total $ 0 00 $ 0 00 Loan Reportng Name of Lender Date of Loan of Loan Electon Cycle** Person(s) responsble for repayment of loan I. Occupaton & Place of Employment Fducary Relatonshp***. 1.. Reference: OCGA 1--(b)(l) Loan Page Total Contrbuton Type (Monetary, In-Knd, Common Source, Credt Receved on Loan) Electon Cycle (Prmary. General, Specal, Specal Prmary. Run-Off Prmary, Run-Off General, Run-Off Specal. Run-Off Specal Prmary) ** If any such person(s) shall have a fducary relatonshp to t ttuton or party makng the advance or extenson of cred Publc Offcer/Canddatt/Non-Canddate Commttee Name Page of

5 SEC FORM CC'DR Itemzed Expendtures Must lst expendtures made to a sngle recpent for whch the assresate total s SlO.OO or more Lst Name and of Recpent Expendture Date Expendture Type* Occupaton & Employer Expendture Purpose Pad Page Total * Expendture Type (Expendture, In-Knd, Loan Repayment Refund, Rembursement, Credt Card, rd Party, Deferred Payment, Payment on Deferred Expense, Investment) Publc OffceVCanddate/Non-Canddate Commttee N:

6 SEC FORM CCDR Rev / Investment Name Insttuton/Person Investments Statment Account Number Value at begnnng of reportng perod $ Cty, State, Zp Value at end of reportng perod $ Dfference n value $ Interest Pad Out $ Cash Dvdends $ Investment Transactons Date Personf s Involved n Transacton Value of nvestment purchased Value of nvestment sold Proft Loss. Investment Name Account Number In sttuton/p erson Holdng Account Mal ng Address Cty, State. Zp Investment Transactons Date Person(s) Involved n Transacton Value of nvestment Dn-chased Value at begnnng of reportng perod $ Value at end of reportng perod $ Dfference n value $ Interest Pad Out $ Cash Dvdends '$ Value of nvestment sold Proft Loss Total value of nvestments at beunnne of reportng perod Page Total Cash Dvdends S 0 00 Total value of nvestments at end of reportng perod Total dfference n value q /W Publc Offt-er/Canddate/Non-Canddate Commttee Name LMgSg Wf* Page Total Interest Pad Out Page Total Proft Page Total Loss