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HomeMy WebLinkAbout19M12 CAMPAIGN TREASURER'S REPORT SUMMARY OFFICE USE ONLY Name (2) Address (number and street) Rec..;v. Date: r-_E�(Y City,State, Zip Code _ ❑ Check here if address has changed (3) ID Number: (4) Check appropriate box(es): ❑ Candidate Office Sought: Q r );7- R 7❑ Political Committee(PC) ❑ Electioneering Communications Org. (ECO) ❑ Check here if PC or ECO has disbanded ❑ Party Executive Committee (PTY) ❑ Check here if PTY has disbanded ❑ Independent Expenditure (IE) (also covers an ❑ Check here if no other IE or EC reports will be filed individual making electioneering communications) (5) Report Identifiers Cover Period: From Z / / To / / Report Type: ❑ Original ❑Amendment ❑ Special Election Report (6) Contributions This Report (7) Expenditures This Report Monetary Cash & Checks $ Expenditures $ Loans $ _ Transfers to Office Account $ SU Total Monetary - Total Monetary $ In-Kind $ (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ ice- (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) (Type name) ° ❑lndnridual(only for IE [`Treasurer ❑Deputy Treasurer Candidate ❑Chairperson(only for PC and PTY) or electioneering comm.) X Signature�° :�` Signature SEE REVERSE FOR INSTRUCTION DS-DE 12(Rev.11113) W CAMPAIGN TREASURER'S REPORT —ITEMIZED CONTRIBUTIONS (1) Name - (2) I.D. Number (3) Cover Period / / through ? / .L� / (4) Page of (5) (�) (8) (�) (10) (11) (12) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address& Contributor Contribution In-kind Amendment Amount Number City,State,Zi Code T e Occu ation T e Descri tion I I I I I I I 1 1 DS-DE 13(Rev.11!13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES