Polk, III., John (Jay)
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For State and Local Candidates
For Single-Candidate Committees
1. DATE OF REPORT 12.a. NAME OF CANDIDATE OR COMMITTEE
2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE
4.a. CAMPAIGN ADDRESS AND PHONE
Street or Rural Route City State Zip Code Phone
4.". CANDIDATE'S H OM`s ADDRESS (if differan. than 4.s.)
Street or Rural Route City State Zip Code Phone
5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate)
7. CATEGORY OR REPORT (Check one) 11 1:1 1:1 FIRST SECOND THIRD F KAR PRE- P❑RE- MID-YEAR ~ND
QUARTER QUARTER QUARTER R PRIMARY GENERAL SUPPLEMENTAL UPPLEMEENTAL
8.a. BEGINNING DATE OF REPORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIOD
0.
9. (Check one)
a. his campaign is exempt from detailed disclosure because contributions (including in-kind) received total $1,000 or less AND expendi-
tures total $1,000 or less for this reporting period. (Complete items 12d., 12e. and 12f.)
b. ❑ This campaign is required to file a detailed financial disclosure because contributions (including in-kind) received total more than $1,000
and/or expenditures total more than $1,000 for this reporting period.
10. I/we do solemnly swear or affirm that the information contained in this campaign financial disclosure report is true and that this report is an
accurate accounting of campaign contributions and expenditures required to be reported by the candidate committee by the Campaign
Financial Disclosure Act. Additionally, I/we swear or affirm that no campaign contributions have been expended for the personal financial
benefit of the candi a or for any other nonpolitical purpose as defined by the federal internal revenue cod
j.
zy it
g re candidate date signature political treasurer date
11. WITNESS SIGNATURE
signature of witness date signature of witness date
12. SUMMARY
P~ FM
a. BALANCE ON HAND LAST REPORT 11
b. TOTALRECEIPTS THIS PERIOD
$
g 1p11
C. TOTAL DISBURSEMENTS THIS PERIOD 1PN $
d. BALANCE ON HAND (12.a. plus 12.b. minus 1~.........LEJ......... $
e. TOTAL LOANS OUTSTANDING $
f. TOTAL OBLIGATIONS OUTSTANDING $
AWL
CXV SS-1109 (Rev. 2106) Page 1 of RDA 1159
MEW