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Pill in Reporting Period da[es: Reginning Date: � Ending Da[e: �
"Cype of Report: (Check one)
� 81h day p�eccding p�elimi�ary ❑ 8th day preceding election �30 day eflec election � yeer-end�eport ❑ dissolution
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OfGcc Sought and Disriel Name nf CommiVcc Trwmrer
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Residcmiel Address CommiVee Meiling Addass
TelepFonc Number(optionep�. 'I'elepFnne Numbcr(optional7�.
SUMMARY BALANCE INFORMATION:
Linel: EndingBalancefrompreviousreport �— �j��.50 yv� �p�y
Line 2: Total ceceipts this period(page 3, line 11) � Z �
Line3: Sublotal Qine l plus line 2) ���
Line 4: Total expendimres this period(page 5, line 14) D
Lice 5: Ending Balance(linc 3 minus line 4) —'S�3 �S�
Line 6: Total in-kind contributions[his pe�iod(page 6) //�_ z3
Line 7: Total (all)outstanding liabilities(page7) �
Line S: Namc of bank(s)uscd:
nma,�n orcomm�n...r.�,��.«:
���u5�fia�i nn�r�ammoa�n�s reo��•�mowa��s n�m�n�a son�d�i<s a�o����m m�e�i onny koowi�e��a�d eerrr,o m��a�a�o�,vie�e��mr�,e�i oren<amne�s�r��a�u
activiq�.ineluding nll mnieibmions,loans,roecip�s.expendiwres dlsbursemems,in-kind convibutions end liabllhies tor ih6 rcponing penod anJ mprezenu�Fc rempaign
fiwnce acfivity olell persons anin6 under�M1e awM1ori�y or on behWf ofiM1is commiuee in uecordence whM1 tM1e requiremen6 ot M.oJ_c.i5.
Signeaondn�xepmxl0esotperjury: fTmasurcr'ssisnawrel Date:�
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mwrted nny liebiliiics nor made my cependimrcs on my bcM1elfduring iFis reponin@ pen�#
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cempaign fnanw nmviiy ofall persons eming underiFe umFovip�or on M1eFAfoflM1is commiVm in ocmrdence wf�F the requiremcn�s ot M GJ..c.55.
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signeaunaerihen��+���esofprtjuqe (Cmdi�a�c'ssignamm7 Date: P' lI�
SCHEDULE A: RECEIPTS
iLf Ql. c. JJ requires lhai!he name and r'esidentiaf addre.rs be repor(ed, in alphabetical order.for all r'eceipts over 3i0 in a cafendar
year. Committeea'must keep detai7ed aceoemts nnd r'erords oJall rereip(s. but need only itemice Ihose receipts over 3J0. /ii addiGan, !he
accupalion and employer'mus!be reporled fa�all per',eons who contrihine 5200 or'nim'e!tt a calenilar'Vear.
(A"Schedule.4: Receipts" attachment is available ro complete,print and auach m this report,it aJdi[ional pages are required to
report all receip[s. Please include your mmmil�ee name and a page number on each page.)
Name and Residential Address Occupa[ion & F.mployer
Datc Received (alphabetical listing required) Amoun[ (for conaibu[ions of 5200 or more)
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Line 9: To[al Receipls over$50(or lisled above) �
Line 10: Total Receipls$50 and under* (mt lis'led above) �
Line 11: TOTAL RF.CEIPTS IN TNE PERIOD � �— Ente�on page I,line 2
' Ifyou have iremized receipts oC$50 and undeq include thcm in line 9. Line 10 should inclode only those receipts not itemized ebove.
Page 2
SCHEDULE B: EXPENDITURES
dLG.L. c ).i reguires commi[tees[o lis[ in a(phabe(ical order', afl exnenditur'es over S�0!n a r'eporGng period Commil[ee�mrvst keep
detaileAacrounGv and recor'ds of al(upendi[vr'e.v. bu[need only ilemi=e tho�ne over 550. L'a�penditures.SJO ond mider mw be added mgether',
jrom co»iminee reaords, and repa'ted on]ine [3.
(A"Schedule e: Expcnditures" at[achment is available ro wmplete,print and a[tach�o Ihis repon,if additional pages are required[o
reporl all expenditures. Pleasc include your commi[[ee name and x page number on each page.)
To Whnm Paid
Da[ePaid (alphabetieallis[ing) Address PurpoaeofExpendi[ure Amount
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Line 12: Total Expendilures ovcr$50(or IisteA above) �
Line 13:Total Gxpendilures $50 and under* (mt listed above) �
En�er on page I,line 4—� Line 14: TOTAL EXPENDITURES IN THE PERIOD .�
• If you have itemized expendiWres of$50 and undec include lhem in line 12. Line 13 should include only those expendi�ures not i[emized
above. Page4
SCHEDULE C: '7N-KIND" CONTRIBUTIONS
Please itemize wntributors who have madc in-kind contributions of more[han$50. In-kind con[ribuiions$50 and onder may be
addeA together Crom the committee's records and included in line 16 on pagc I.
Da[e Received From Whom Received* Residen[ial Addrese Descrip[iou of Contribu[ion Value
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2Z � ✓vIaSS cl iF5 S�n �000 pZ ot f0u(� � ol,�> � I�I. L�7
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Line I5: In-Kind Contribu[ions over$50(or listed above) �
I,ine 16: In-Kind Contcibutions$50& under(not listed abovc)�
6n�cron page I,line 6 -� Line 17: TOTAL IN-KIND CONTRIBUTIONS ���. Z.3
* Ifan in-kind contribWion is received from a person who conhibutcs more than$50 in a calendar year,you must report�he name and address
ofthe cmtributor; in additiort. ifthe contribution is$200 or more,yoo must also repon the contributor's occupation and employer. page 6