HomeMy WebLinkAbout07: M05-17 ReportCAMPAIGN TREASURER'S REPORT SUMMARY
OFFICE USE ONLY
By
(1)
Name ^
(2)
Address (number and street) )
City, State, Zip Code
O Check here if address has changed
(4) Check appropriate box(es): ^
QjX^ndidate Office Sought:
(3) ID Number:
□ Political Committee (PC)
□ Electioneering Communications Org. (ECO)
□ Party Executive Committee (PTY)
□ Independent Expenditure (IE) (also covers an
individual making electioneering communications)
n Check here If PC or ECO has disbanded
G Check here if PTY has disbanded
G Check here if no other IE or EC reports will be filed
(5) Report IdentifiersCover Period: From Report Type: fY) ' Cj-
G Original G Amendment G Special Election Report
(6) Contributions This Report
Cash & Checks $ . |
Loans
Total Monetary
In-Kind
OO
(7) Expenditures This Report
Monetary
Expenditures $
T ransfers to
Office Account $
Total Monetary^ $
(8) Other Distributions
$
(9) TOTAL Monetary Contributions To Date
$ , K .
(10) TOTAL Monetary Expenditures To Date
$ . , oO
(11) Certification
It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.)
I certify that i have examined this report and it is true, correct, and complete:
(Type name) '0{Z, (Type name) 'C (^4-fo_D/KtO
□ individual (only for IE □ Treasurer Q^puty Treasurer n^andidate
or electioneering comm.)
□ Chairperson (only for PC and PTY)
X
Signature Sign
DS-DE 12 (Rev. 11/13)SEE REVERSE FOR INSTRUCTIONS
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name \Z -L(J74-K (2) |.D. Number
(4) Page(3) Cover Period ^ / _[ / ^ ^ through / 5 ^ / I I of I
(5)
Date
(6)
Sequence
Number
(7)
Full Name
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
(8)
Contributor
Type Occupation
(9)
Contribution
Iffie
(10)
In-kind
Description
(11)
Amendment
(12)
Amount
00
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DS-DE13 (Rev. 11/13)SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES