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