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Webb, Tony [Fred Anthony] Appointment of Political Treasurer For State and Local Candidates and Single-Candidate Committees INSTRUCTIONS The Appointment of Political Treasurer statement must be used to appoint a political treasurer as required by the Campaign Financial Disclosure Act (T.C.A. § 2-10-105) for state and local candidates and single- candidate political campaign committees. A state candidate may not receive or expend funds for an election until a political treasurer has been appointed for that election. A local candidate pursuant to T.C.A 2-10-101, may be exempt from completing this form, please check with county election commission for more information. A candidate may appoint himself or herself as political treasurer. A new form must be filed if the treasurer is changed. Candidates for state public office must file their original Appointment of Political Treasurer statement ONLY with the Registry of Election Finance, 404 James Robertson Parkway, Suite 104, Nashville, TN 37243-1360. Candidates for local public office must file their original Appointment of Political Treasurer statement ONLY with their county election commission. 1. Date: 2. Name of Candidate or Co mittee: 3. Candidate e-mail address: " IF I kl~Lk ] Ls~~ Q •r, 4. Campaign Address and Phone: City State Zip Code Pho a loci S ; l~~ 5. Home Addfess-and Phone (if different than item 4 above): City State Zip Code Phone 6. Office Sought (include district number, if applicable) 7. Party Affliation 8. Election Year qt r Fc hiff), skk? ~-I 9. Treasurer Name: *10. Treasurer a-mail address: IAJ P, 11. Treas rer Addre and Phon : City State Zip Code PijQnQ, V i( T~ 12. Candidate and Treasurer Sig ture (both signatures must be witnessed. Tr asurercan not witness candidate's signature): Si ature Candidate "9n re of Treasurer Signature of Witness Signature of Witness Registry of Election Finance SS-1120 (rev 1012010) CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 2.a. NAME OF CANDIDATE OR C MMITTEE 2.b. IF COMMITTEE, NAME F CANDIDATE 3. ELECTION DATE 4.a. CAMPAIG ADDRESS AND PHONE Street or Rural Route City State Zip Code Phone O 1.3 i Tver v~'I 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone 5. OFFIC SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURE (may be candidate) a 2 7. CATEGORY R REPORT i Check one) ❑ ❑ ❑ ❑ ❑ FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF REPORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIOD 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 candidate or for any other nonpolitical purpose as defined by the federal internal revenue cod . signat e f candidate date signatur up Iitical treasurer date 11. WITNESS SIGNATURE q, (0--( Z (o-0 signature o witness date signature of ess date 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ b. TOTAL RECEIPTS THIS PERIOD _t $ 64~ c. TOTAL DISBURSEMENTS THIS PERIOD o i:....., $ d. BALANCE ON HAND (12.a. plus 12.b. minus 12.0 OJNI . f V $ ~9 e. TOTAL LOANS OUTSTANDING $ f. TOTAL OBLIGATIONS OUTSTANDING $ SS-1109 (Rev. 2/06) Page 1 of RDA 1159 CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. iATEOF 22 REPORT ~ J I2.a. NAME OFCANDIDATE O tOt~EE 8 2.b. IF COMMITTEE, NAME O CANDID TE 3. ELECTION DA d 4.a. CAMPAIGN 4fDDRESS AND PHONE Street or Rural Route City State Zip Code Phone 01 J p . (VLmi yr l l2 tSl 105• ~i' 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone 5. OFFICE SOUGH (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) CATEGORY OR REPORT (Check one)❑ ❑ ❑ ❑ ❑ FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEA -END QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF REPORTING PERIOD 8.b. ENDING DATE OFREPORTING PERIOD 9. (Check one) a. This campaign is exempt from detailed disclosure because contributions (including in-kind) received total $1,000 or less AND expendi- ture otal $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 $1,000 for this reporting period. 10. I/we do solemnly swear or affirm that the information contained in this campaign financial disclosure report is true and that this report is an accurate accounting of campaign contributions and expenditures required to be reported by the candidate committee by the Campaign Financial Disclosure Act. Additionally, I/we swear or affirm that no campaign contributions have been expended for the personal financial benefit of the c didate or for any other nonpolitical purpose as defined by the federal internal revenue Idle. CIA s ture of candidate date signatu political treasurer ate 11. WITNESS SIGNATURE r.2"-I$ 'i~~ \-2q-c signature o s date signature of witness date 12. SUMMARY q9,-1F a. BALANCE ON HAND LAST REPORT b. TOTAL RECEIPTS THIS PERIOD $ c. TOTAL DISBURSEMENTS THIS PERIOD $ d. BALANCE ON HAND (12.a. plus 12.b. minus 12.%QIJNTCOUf~m ( $ . e. TOTAL LOANS OUTSTANDING $ I f. TOTAL 0 B LI GATI 0 N S OUTSTANDING $ 1 m5;r SS-1109 (Rev. 2/06) Page 1 of RDA 1159 CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DUE OF REPORT - 12.a. E OF CANDID E OR C MM ~r 2.b. IF COMMITTEE, NAME OF AN ID TE 3. EL~FN DATE 4.a. CAMPAIGN AD ESS AND PHONE Street or Rural T ity - State Zip Code Phone V v go -'386 0j( l o SF;--~CretekLn. M0j_V 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) 49t_r~ or Rural Route City State Zip Code Phone 5O F I E SO GHT (inclu h trict btif p li ) 6. N AM~ OF POLITICAL RE U may be candidate) is 0 U~~ [ I 9~tw 7. CATE Y OR R PORT (Check one) 1:1 1:1 FIRST SEND THIRD FOURTH PRE- PRE- MID YEAR❑-END QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGI I DATE OF REPO TING PERIOD 1 r, 8.b. E DATE OF REPORTING PERIOD 9. (Check one) a. ❑ This 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. is 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 t of the candidate for any other nonpolitical urjjose as defined by the federal internal reve a code. - c OP2t"- 16 signatur of andidate date signat re f political treasurer date 11. IT ESS SIGNATURE signature o witness date Sig Hess date 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ . . . b. TOTAL RECEIPTSTHIS PERIOD ................../~:.:.............F1 . ECEIVED . c. TOTAL DISBURSEMENTS THIS PERIOD JU......L...2 1 2016......................................... $ ">LOUNT COUNTY d. BALANCE ON HAND (12.a. plus 12.b. minu6,12:c.) .....Iw~.EGA(~I` $ -_j IL J_~ O e. TOTAL LOANS OUTSTANDING - ~r...;,:..;:..G.,........................................................... $ Cl f. TOTAL OBLIGATIONS OUTSTANDING $ SS-1109 (Rev. 2/06) Page 1 of RDA 1159 CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE REPORT 12.a. NAMEOFCAN IDATEORCO M EE 2.b. IF COMMITTEE, NAME OF N ID TE 3. ELECTION DART9 7'© 4.a. CAMPAIGN ADD ESS AND PHONE Street or Rural R ute City State Zip Code Phone IB' Car c~l~ 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.1) Street or Rural Route City State Zip Code Phone 4k4 4M 9==-- ~O ICE POUG T (include district umbel, i pli ) 6. NAM ® POLITICAL TREAS R NR ( ay be candidate) r 7. CATEGORY ORREPORT (Chec one) FIRST SEND THIRD FOURTH P1:1 Ef RE- PRE- MID-YEAR YEAR❑-E ND QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNI DATE OF REPORTING PERM 8.b. ENDING DATE OF REPORTING PERIM E V,.' tC 9. (Check one) a. ❑ This 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. his 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 candidate or for any other nonpolitical ,purpose-as defined by the federal internal rev ue code. VZ I X ( 1!-'~ igna re of candidate date sign ure f political treasurer date 11. WITNESS SIGNATURE signature of witness date signature of witness date 12. SUMMARY 12 AM a. BALANCE ON HAND LAST REPORT 1....................... $ a~ ti C b. TOTAL RECEIPTS THIS PERIOD ~ ~....0~~ . ~ N. Q ~1r c. TOTAL DISBURSEMENTS THIS PERIOD . v $ d. BALANCE ON HAND 12.a. plus 12.b. minus . $ ' Z4 e. TOTAL LOANS OUTSTANDING $ f. TOTAL OBLIGATIONS OUTSTANDING $ SS-1109 (Rev. 2/06) Page 1 of RDA 1159 } CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 2.a NAME OF CAN ID TE R C TTE ~ 2.b. IF CEE, NAME O CA DI T 3. ELECTI DAT 4.a. CAMPAIGN ADD SS AN PHONE Street or Rural Route City State Zi Code Phone ' , ~j, )/,L.TN , 3@& ~ 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Str t or Rural Route City State Zip Code Phone OFFI E SOUGH (include district nu er, if appli le) 6. NAME OF POLITICAL T A URER (may be candidate) I5 N C- ~ Q 7. CATEGORY OR REPORT (Check one) ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DDAAT)E OF REPORTING PER D 8.b. ENDING DATE PORTING PERIOD I " ~ I j C17 9. (Check one) a. ❑ This campaign is exempt from detailed disclosure because contributions (including in-kind) received total $1,000 or less AND expendi- tures $1,000 or less for this reporting period. (Complete items 12d., 12e. and 12f.) b. his 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. itionally, I/we swear or affirm that no campaign contributions have been expended for the personal financial b efit of the candidate o for ny othe nonpolitical purpose as defined by the federal internal revenue code. signat e o andidate date nature poll I treasurer dale 11. [WITNESS SIGNATURE 1 -~5 1-24~ -f signature of witness date signature of witness date 12. SUMMARY 49 a. BALANCE ON HAND LAST REPORT $ b. TOTAL RECEIPTSTHIS PERIOD c. TOTAL DISBURSEMENTS THIS PERIOD $ 7 d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) $ e. TOTAL LOANS OUTSTANDING $ ' V . f. TOTAL OBLIGATIONS OUTSTANDING $ SS-1109 (Rev. 2/06) Page 1 of RDA 1159 SUMMARY PAGE - CANDIDATE 13. E OF CANDI TE R OMMITTEE (In Full) 14. REP RT CO ING THE PERIO FROM: TO: RECEIPT 15. CONTRIBUTIONS (other than loans and interest) a. Unitemized Contributions ($100 or less from each source this period) $ b. Itemized Contributions (over $100 from each source this period) $ c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ 16. LOANS RECEIVED THIS REPORTING PERIOD $ 17. INTEREST RECEIVED THIS REPORTING PERIOD $ 18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.) $ DISBURSEMENTS 19. EXPENDITURES (other than loan payments) a. Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage, gasoline) Total of Expenditures ($100 or less each payee) $ b. Itemized Expenditures (Over $100 each payee this period) $ c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ 20. LOAN REPAYMENTS MADE THIS PERIOD $ 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ 22.IN-KIND CONTRIBUTIONS a. Unitemized in-kind contributions ($100 or less from each source this period) $ b. Itemized in-kind contributions (over $100 from each source this period) $ c. TOTAL IN-KIND CONTRIBUTIONS RECEIVED THIS PERIOD (add 22.a. and 22.b.) $ 23. OBLIGATIONS a. Unitemized Obligations Outstanding ($100 or less each) $ b. Itemized Obligations Outstanding (Over $100 each) $ c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 121.) $ AML SS-1133 (Rev. 4102) Page of CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF EPORT ~ ~ 4 4 12. NAME OF CANDI T O O EE' I c) t-N 3. ELEC N D 2.b. IF TEE, NAME OF C N DA ` h 4.a. CAMPAIGN ADDR SS AND PHONE State Zip Coe Phone Street or Rural Roue ty ` / J ~ I 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) State Zip Code Phone Street or Rural Route City OFFI SQUGHT include district n ber, i applicable 6. NAME OF POLITICAL TREA URER (m y be candidate) . ~c U ❑ ❑ ❑ ❑ 7. C EGORY OR REPORT (Check ones FIRST T SECOND FOURTH PRE- PRE- MID-YEAR YEAR-END SUPPLEM QUARTER QUARTER QUARTER QUARTER PRIMARY DATE OF REPORTING PER ODEM~ SUPPLEMENTAL 8.a. BEGINNING DATE OF 11, PORTING P RIOD O 9. (Check one) a. ❑ This 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, his 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 candida or for any other nonpolitical purpose as defined by the federal internal revenue ode. t! a. , I q 4~__ a,_ date signatu of litical treasurer ate signa r of candidate 11. WITNESS SIGNATURE (QL-LO A& date signature of witness date signa ure of witness 12. SUMMARY -g a. BALANCE ON HAND LAST REPORT $ b. TOTAL RECEIPTS THIS PERIOD $ c. TOTAL DISBURSEMENTS THIS PERIOD $ ~~e7 $ d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) t $ e. TOTAL LOANS OUTSTANDING $ f. TOTAL OBLIGATIONS OUTSTANDING Page 1 of C RDA 1159 SS-1109 (Rev. 2106) SUMMARY PAGE - CANDIDATE 13. N OF CANDIDAT O C MMITTEE (In Full) 14. R R G THE PERIOD C r FROM: 0: ! G` RECEIPTS 15. CONTRIBUTIONS (other than loans and interest) a. Unitemized Contributions ($100 or less from each source this period) $ b. Itemized Contributions (over $100 from each source this period) $ c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ 16. LOANS RECEIVED THIS REPORTING PERIOD $ 17. INTEREST RECEIVED THIS REPORTING PERIOD $ 18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.) $ DISBURSEMENTS 19. EXPENDITURES (other than loan payments) a. Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage, gasoline) Total of Expenditures ($100 or less each payee) $ b. Itemized Expenditures (Over $100 each payee this period) $ c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ 20. LOAN REPAYMENTS MADE THIS PERIOD $ 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ 22.IN-KIND CONTRIBUTIONS a. Unitemized in-kind contributions ($100 or less from each source this period) $ b. Itemized in-kind contributions (over $100 from each source this period) $ Z_- , c. TOTAL IN-KIND CONTRIBUTIONS RECEIVED THIS PERIOD (add 22.a. and 22.b.) $ 23. OBLIGATIONS a. Unitemized Obligations Outstanding ($100 or less each) $ b. Itemized Obligations Outstanding (Over $100 each) $ Cam. c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 12.f.) $ SS-1133 (Rev. 4102) Page of ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME NDIDATE OR CO MI EE 2 BEEQV4 COVER LNG THE PERIOD DA' TO: Amount 3. TOTAL ITEMIZED CAMPAIGN CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED CONTRIBUTION contributions totaling more than $100 from an contributor First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) Cay State Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name IM iddle Name Contribution Received For: Amount of Contribution as am rganiza on Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer 5. TOTAL ITEMIZED CONTRIBUTIONS (Carry forward to item 3. of next page if additional pages of this form are used.) (If this is the last page of contributions, this amount must be shown in item 15b. of summary.) SS-1131(Rev. 2/06) Page of RDA 1159 ITEMIZED STATEMENT OF IN-KIND CONTRIBUTIONS - CANDIDATE 1. NAM 0 CANDIDATE OR CO MI EE 2. R CO E ING THE PERIOD F TO: - mount 3. TOTAL ITEMIZE IN-KIND CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED IN-KIND CONTRIBUTION (in-kind contributions totaling more than $100 from any contributor during the period) First Name Middle Name I Ki d Contribution Received For: Value of In-Kind Contribution Primary Election ❑ General Election LastNamelOrg nName 26 y~' /Runoff (Local Elections Only) Address Date ofn nd Col 4 Aggregate this Election Ci Description of In-Kind Contribution Occupatio Em Dyer ir ZL-~ G LIwLctc -6 First Name Middle Name In-Kind Contribution Received For: Value of In-Kind Contribution ❑ Primary Election ❑ General Election Last Name/Organization Name ❑ Runoff (Local Elections Only) Address Date of In-Grid Contribution Aggregate this Election City State Zip Code Description of In-Kind Contribution Occupation Employer First Name Middle Name In-Kind Contribution Received For: Value of In-Kind Contribution ❑ Primary Election ❑ General Election Last Name/Organization Name ❑ Runoff (Local Elections Only) Address Date of InAnd Contribution Aggregate this Election city state Zip Code Description of In-Kind Contribution Occupation Employer First Name Middle Name In-Kind Contribution Received For: Value of In-Kind Contribution ❑ Primary Election ❑ General Election Last Name/Organization Name ❑ Runoff (Local Elections Only) Address Date of InAnd Contribution Aggregate this Election City State Zip Code Description of In-Kind Contribution Occupation Employer First Name Middle Name In-Kind Contribution Received For: Value of In-Kind Contribution ❑ Primary Election ❑ General Election -7 Last Name/Organization Name ❑ Runoff (Local Elections Only) Address Date of In-Kind Contribution Aggregate this Election City State Zip Code Description of InXind Contribution Occupation mp oyer 5. TOTAL ITEMIZED IN-KIND CONTRIBUTIONS (Carry forward to item 3. of next page if additional pages of this form are used.) (If this is the last page of in-kind contributions, this amount must be shown in item 22b. of summary.) SS-1128 (Rev. 2/06) Page of RDA 1159 ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAM DIDATE OR ffOMITTE T CO ING T ERI 0 TO: [c) t C) E. I Amount 3. TOTAL ITEMIZED C MPAIGN EXPENDITURES FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED EXPENDITURE (expenditures totaling more than $100 to any payee during the period) First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last NamelBusiness Name Address City State Zip Code 5. TOTAL ITEMIZED EXPENDITURES (Carry forward to item 3. of next page if additional pages of this form are used.) (If this is the last page of expenditures, this amount must be shown in item 19b. of summary.) AI& SS-1129 (Rev. 4102) Page of RDA 1159 ITEMIZED STATEMENT OF LOANS - CANDIDATE 1. NAME OF CANDIDATE OR COMMIT EE 2. REPORT COVERING THE PERIOD M. / T~ O C)vl 3. COMPLETE THE APP OPRIATE ITEMS FOR EACH ITEMIZED LOAN (loans totaling more than $100 from any source during the period) Complete the Following for the Source of the Loan First Name Middle Name Outstanding Loan Balance Loans Loan Outstanding Loan Balance . (Beginning of Period) Received Paymen (End of Period)`'~/ Last Name/Organization Name ~o 2, ® Address Loan Received For: Date of Loan ❑ Primary Election ❑ General Election City State Zip Code ❑ Runoff (Local Elections Only) List All Endorsers or Guarantors for Above Loan (If more space is needed please attach a page) First Name Middle Name First Name Middle Name Last NamelOrganization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding mount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code city State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding 4. Totals for all Loans (complete on last page of itemized loans) Outstanding Loan Balance Loans Loan Outstanding Loan Balance is End of Period (Total loans received should also be shown in item 16. on summary page.) (Beginning Period Receiv d Pa in (Total loan payments should also be shown in item 20. on summary page.) (Total outstanding loan balance should also be shown in item 12.e. on front page.) v Aftk SS-1132 (Rev. 4/02) Page ~ of RDA 1159 CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 1- 12.a AME OF ANDIDA COMMITTEE r~ C'o'd i Q_ 2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE 4.a. CAMPAIGN DRESS A RD PHONE Street or Rura Route City State Zip Code Phone 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone 5. a OF ICE S LIGHT (include district number, if a licable) 6. NAME OF POLITICAL T AS R (may be candidate) 7. CATEGORY OR REPORT (Check one) ❑ ❑ ❑ ❑ ❑ ❑ ❑ FIRST SECOND THIRD FOURTH PRE- MID-YEAR YEAR-END QUARTER QUARTER QUARTER QUARTER PRI RY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF REPORTI PERIOD 8.b. ENDING DATE OF REPORTING PERIO 9.(Check one) a. ❑ This 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 en fit of the candidate or for any other nonpolitical purpose as defined by the federal internal re nue code. r~k _,_I ,3 - 4 7 signatu e o candidate date s re of potffical treasurer date • 11. WI NESS SIGNATURE signature of witness date signature of witness date E' - 7'; 12. SUMMARY u a. BALANCE ON HAND LAST REPORT . $ I JG....... ~~v............ no b. TOTAL RECEIPTS THIS PERIOD c. s............ $ v . . C. TOTAL DISBURSEMENTS THIS PERIOD c $ 7 V d. BALANCE ON HAND (12.a plus 12.b. minus 12.c.) .6...g..~ $ 4q, C C> e. TOTAL LOANS OUTSTANDING $ , f. TOTAL OBLIGATIONS OUTSTANDING $ SS-1109 (Rev. 2106) Page 1 of RDA 1159 ITEMIZED STATEMENT OF LOANS - CANDIDATE PERIOD 1. NAME OF CANDIDATE OR COMMITTEE . J~ 2. REPORT +COVERING THE FR T114'Ld-_ r 1 3. COMPLET THE APPROPIRTE ITEMS FOR EACH ITEMIZED LOAN (loans totaling more than $100 from any source during the period) Complete the Following for the Source of the Loan Fire Middle Name Outstanding Loan Balance Loans Loan Outstanding Loan Balance (Beginning of Period) Received Payments (End of Period) Last /Orga 'zatio Name CC> Nm ~3 \~J. C Address c can Received For: Date of Loan O I J( V ® Primary Election ❑ General Election 1 I I ✓ 1 I . Runoff (Local Elections Only) i List All Endorsers or Guarantors for Above Loan (If more space is needed please attach a page) Firs e Middle Nam First Name Middle Name Las Nam /Orga izatio Name Last Name/Organization Name e 1djr6 13 ` I ` re-Address V I Slab,- e~ City State Zip Code Amount Guarantee Outstanding 25( ✓p0 mount Guaranteed Outstanding F irst Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding 10 - First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding 4. Totals for all Loans (complete on last page of itemized loans) Outstanding Loan Balance Loans Loan Outstanding Loan Balance (lotal loans received should also be shown in item 16 on summary page.) (Beginning of Period Received Pa menu End of Period (Total loan payments should also be shown in item 20. on summary page ) (Total outstanding loan balance should also be shown in item 12.e. on front page.) Gd W . / -,Sjo . 0 SS-1132 (Rev. 4102) Page of RDA 1159 ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. ME OF CAN IDATE OR ZOITTV 2. REPORT COVERING THE P IOD III Il G FROM: TO: Amount 3. TOTAL ITEMIZED CAMPAIGN CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITFMIZED CONTRIBUTION (contributions totaling more than $100 from an contributor) First Name Middle Name Contribution [Received For: Amount of Contribution i ast Name/Organization Name ❑ Primary Election ❑ General Election Dal'( vu. Address ~ 2) A , El Runoff (Local Elections Only) ) ZipCm~ Date of Contribution Aggregate This Election City ~~A I ]W I M Occupation I J Fmployer iirstName Middle Name Contribution Received For: Amounl of Contribution ax NamelOrgamzatonName ❑PrimaryElection ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer ustName iddleNarric Contribution Received For: Amount of Contribution ast Name /Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer I iist Name Middle Name Contribution Received For: Amount of Contribution t ast Nan ielOrganization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Lmployer 5. TOTAL ITEMIZED CONTRIBUTIONS (Carry forward to item 3. of next page it additional pages of this form are used.) (If this is the last page of contributions, this amount must be shown in item 15b. of summary.) SS-1131(Rev. 2106) Page of -!S~7 RDA 1159 ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: T0: -11 Ll ILL I'll I Amount 3. TOTAL ITEMIZED CAMPAIGN EXPENDITURES FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED EXPENDITURE (expenditures totaling more than $100 to any payee during the period) First Name Middle Name Purpose of Expenditure Amount of Expenditure ~y~~/SIt1 Last NIp~si ess lame U' d 5~ rs f 511c.~r ; Address -7 r4) ov . -AIPW NN 1 (4 U', ct zip"lA,br~c~. First Name Middle Name vt Purpose of Expenditure Amount of Expenditure Last NamelB i e 1 Address { LK 440 City , Zip Code ' I W in tA I irst Name Middle Name Purpose of Expenditure Amount of Expenditure amElB I C4 C.- ~ usinessN z4 1 Add ~ ~ 1 42q7.43City State Zip Code t first Name Middle Name Purpose of Expenditure Amount of Expenditure i asl Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code first Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code 5. TOTAL ITEMIZED EXPENDITURES (Carry forward to item 3. of next page if additional pages of this form are used.) (If this is the last page of expenditures, this amount must be shown in item 19b. of summary.) 01 SS-1129 (Rev. 4102) Page of RDA 1159 SUMMARY PAGE - CANDIDATE 13. NAME OF CANDIDATE 0 OMM TTEE (In Full) 14. REPORT COVERING THE PERIOD FN~: - -T'-GV1W We- rcC_ FROM: _ TO:--- I _66 RECEI TS 15. CONTRIBUTIONS (other than loans and interest) a. Unitemized Contributions ($100 or less from each source this period) _ b. Itemized Contributions (over $100 from each source this period) $ _ CFO- c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) 16. LOANS RECEIVED THIS REPORTING PERIOD V O 17. INTEREST RECEIVED THIS REPORTING PERIOD $ 18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.) $ DISBURSEMENTS 19. EXPENDITURES (other than loan payments) a. Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage, gasoline) $ $ $ $ $ ~ ~ DO Total of Expenditures ($100 or less each payee) $ b. Itemized Expenditures (Over $100 each payee this period) $ r V c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ 20. LOAN REPAYMENTS MADE THIS PERIOD $ N43 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ 22.IN-KIND CONTRIBUTIONS a. Unitemized in-kind contributions ($100 or less from each source this period)... $ b. Itemized in-kind contributions (over $100 from each source this period) $ c. TOTAL IN-KIND CONTRIBUTIONS RECEIVED THIS PERIOD (add 22.a. and 22.b.) $ zo/ 23. OBLIGATIONS a. Unitemized Obligations Outstanding ($100 or less each) $ b. Itemized Obligations Outstanding (Over $100 each) $ c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 12.f.) $ SS-1133 (Rev. 4102) Page of CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DAT OFREPORT` 2. a. NAMUN~ORCOMM17EE .~I- ~ --'ei 2.b. IF CO ` TTEE, NAME OF AND1D TE 3. ELECT ON DATE - 4.a. CAMPAIGN ADD ESS AND PHONE Street or Rural Route city % Zip Code Phone r C i rem /I;ate,, r-~~ 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone OFFICES UGHT (include dis rict number, if a li able) 6. NAME OF POLITICAL THE SU ER (may be candidate) rn rn:~ . ~r 7. CATEGORY O R PORT (Check one) ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF EPORTING PERIOD 8.b. ENDING DATE OF REPOR~PERIOD d U (//j(/[h 9.(Check one) a. ❑ This 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 enefit of the ndidate or for any other nonpolitical purpose as defined by the federal internal revenue code. - .,3L- -e-~ AIG igna re of candidate date si atur o olitical treasurer date 11. WITNESS SIGNATURE signature f witness date signature of witness date < qM 12. SUMMARY RECQ :c. -~J a. BALANCE ON HAND LAST REPORT D....... (n JUL 31 1 b. TOTAL RECEIPTS THIS PERIOD `......~t~.N/...I...~U............` A tea. rowry Q__) ' e c. TOTAL DISBURSEMENTS THIS PERIOD ..............1Y.::.... ~V . $ 21 d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) . 1 e. TOTAL LOANS OUTSTANDING $ f. TOTAL OBLIGATIONS OUTSTANDING SS-1109 (Rev. 2/06) Page 1 of As~ RDA 1159 SUMMARY PAGE - CANDIDATE 13. NAM CANDIDAT OR ~ME (In Full) 14. RE RT COVERING T E PERIOD CC>FROM: T0: RECEIPTS 15. CONTRIBUTIONS (other than loans and interest) 322.AV a. Unitemized Contributions ($100 or less from each source this period) $ -70 b. Itemized Contributions (over $100 from each source this period) $ c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ 16. LOANS RECEIVED THIS REPORTING PERIOD .OD 17. INTEREST RECEIVED THIS REPORTING PERIOD 18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.) $ 1172-0 DISBURSEMENTS 19. EXPENDITURES (other than loan payments) a. Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage, gasoline) $ gz -ly tS ct~ cs~• $ 9!~ $ $ 73 ~ $ -L-1~- U $ r $ Total of Expenditures ($100 or less each payee) } ..~Ll.U... $ b. Itemized Expenditures (Over $100 each payee this period) $ c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ 20. LOAN REPAYMENTS MADE THIS PERIOD 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) 22.IN-KIND CONTRIBUTIONS a. Unitemized in-kind contributions ($100 or less from each source this period) $ b. Itemized in-kind contributions (over $100 from each source this period) $ c. TOTAL IN-KIND CONTRIBUTIONS RECEIVED THIS PERIOD (add 22.a. and 22.b.) $ 23. OBLIGATIONS a. Unitemized Obligations Outstanding ($100 or less each) $ b. Itemized Obligations Outstanding (Over $100 each) $ c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 12.f.) $ SS-1133 (Rev. 4102) A"Of-67 of ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME ATE OR COM ITTE 2. REPORT COVERING T PERIOD FROM19~1~ Fm-own 3. TOTAL ITEMIZED CAMPAIGN EXPENDITURES FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED EXPENDITURE (expenditures totaling more than $100 to any payee during the period) First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Nam Addres 14, qb Cit ode First Name Middle Name Purpose of Expenditure Amount of Expenditure Last NamelBusiness Name Address City State Zip Code I first Name Middle Name Purpose of Expenditure Amount of Expenditure Last NamelBusiness Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code 5. TOTAL ITEMIZED EXPENDITURES (Carry forward to item 3, of next page if additional pages of this form are used ) (If this is the last page of expenditures, this amount must be shown in item 19b. of summary.) SS-1129 (Rev. 4102) Page of RDA 1159 ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR CO ITT 2. REPO PT COVERING THE P RI FROM: ' T0: Amount 3. TOTAL ITEMIZED CAMPAIGN CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLI TI 11-1F APPROPRIATE ITEMS FOR I ACH ITEMIZED CONTRIBUTION (contributions totalin more than $100 from an contributor) I first a e Middle Name Contribution Received For. Amount of Contribution Last amel r anitatio am kP rimaryElection ❑ General Election 100.00 Addre .I ❑ Runoff (Local Elections Only) ro cxi--~ t P /Date of Contribution Aggregate This Election Occu EzEa-A Employer f ust Narne Middle Name Contribution Received For: ikmounl of Contribution I ast NamelOfganization Narne ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name iddleName Contribution Received For: Amount of Contribution ast Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City state Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate 1-his Election Occupation Employer 5. TOTAL ITEMIZED CONTRIBUTIONS (Carry forward to item 3. of next page if additional pages of this form are used.) (If this is the last page of contributions, this amount must be shown in item 15b. of summary.) SS-1131(Rev. 2/06) Page of RDA 1159 i ITEMIZED STATEMENT OF LOANS - CANDIDATE 1. NAME OF CANDIDATE OR OMMITT E 2. REPORT COVERING THE PERIOD FRO h\~4 1 TO bWA 0 3. COMPLETE TFtf APPROPRIATE ITEM FOR EACH ITEMIZED LOAN (loans totaling more than $100 from any source during the period) Complete the Following for the Source of the Loan Fi s me Middle Outstanding Loan Balance Loans Loan Outstanding Loan Balance Payments (End of Period) (Beginning of Period) Received -Js am Organ do Name ~ ~"1~ f ~ ~c✓'~ I Address ~ Loa Received For: Dale of Loan d~.J Primary Election ❑ General Election ti 'p- ae Cit ❑ Runoff (Local Elections Only) List All Endorsers or Guarantors for Above Loan (If more space is needed please attach a page) First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last NameiOrganization Name Last NamelOrganization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City Stale Zip Code City Slate Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding 4. Totals for all Loans (complete on last page of itemized loans) Outstanding Loan Balance Loans Loan Outstanding Loan Balance (total loans received should also be shown in item 16. on summary page.) Be innin of Period Received Payments End of Period (lotal loan payments should also be shown in item 20, on summary page.) (Total outstanding loan balance should also be shown in item 12.e. on front page.) 0 SS-1132 (Rev. 4102) Page of RDA 1159 FINANCIAL DISCLOSURE STATEMENT EXEMPTION Pursuant to TCA 5 2-10-101(b) a candidate is exempt from filing financial disclosure statements: "If a candidate is seeking an office for which service is part-time, compensation is less than $1,000 a month, and the candidate does not spend more than $1,000 to get elected to office, the candidate does not have to file Campaign Financial Disclosure Reports." CANDIDATE'S INFORMATION: Candidate's Name: 'TC, k" C z Candidate's Position: 1 M Residential Address: -Lc--)i4 i Lr-r Ln=ake. LQr,,- City: ) I State: TN Zip: I hereby state that I meet the above qualifications for exemption and am therefore exempt from filing financial disclosure statements. r' s Signature Date e l nd ate' Witness's Signature Date If my plans change and I realize I will spend more than $1,000 on my campaign, I will immediately make a financial disclosure report. RECc, jED at Appointment of Political Treasurer For State and Local Candidates and Single-Candidate Committees INSTRUCTIONS The Appointment of Political Treasurer statement must be used to appoint a political treasurer as required by the Campaign Financial Disclosure Act (T.C.A. § 2-10-105) for state and local candidates and single- candidate political campaign committees. A state candidate may not receive or expend funds for an election u ntil a political treasurer has been appointed for that election. A local candidate pursuant to T.C.A 2-10-10 1, may be exempt from completing this form, please check with county election commission for more information. A candidate may appoint himself or herself as political treasurer. A new form must be filed if the treasurer is changed. Candidates for state public office must file their original Appointment of Political Treasurer statement ONLY with the Registry of Election Finance, 404 James Robertson Parkway, Suite 104, Nashville, TN 37243-1360. Candidates for local public office must file the_iroriginal Appointment of Political Treasurer statement ONLY with their county election commission. 2. Name of Candidate or Committee: 3. Candidate e-mail address: 1. Date: d hc< 4. Campaign Adrd Pho ne: w City State Zip Code Phone S. Home Address and Phone (if different than Item 4 a ove): City S to Zip Coe Phone 6. Office Sought (include district number, if applicable) 7. Party Affliction r714 Year _ba.~~~ ~~2 9. Treasurer Name: 10. Treasurer e-mail address: 1 V ~Ve&11. Treasurer Address and Phone: City State Zip Code Phone 12. Candidate and Treasurer Signature (both signatures must be witnessed. Treasurercan not witness candidate's signature): Sign ture f Candidate Sign re of Treasurer 17 Q Signature of Witness Signature of Witness Registry of Election Finance SS-1120 (rev 1012010)