Lewis, Mike
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For State and Local Candidates
For Single-Candidate Committees
1. DATE OF REPORT 12.a. NAME OF CANDIDATE OR COMMITTEE
111171
9 /
c-' E2~,CS
2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE
4.a. CAMPAIGN ADDRESS AND PHONE
Street or Rural Route ity State Zip Code Phone
3 7 70 /
4.b. CAND ATE'S HOME ADDRESS (if different than 4.a.)
Street or Rural 50ute city State Zip Code Phone
i
✓
-17'7o
5. OFFICE SOUGHT nclude district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate)
C~OI,/YT p >/.3S/Cl-t/ i ~ ~PI~H (3 Uc%y93h`a9i/ ,Q.Ye,Q,,
7. CATEGO Y OR REPORT (Check one)
ERI_ ❑ ❑ ❑ ❑ ❑ ❑
FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR❑-E
ND
QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL
8.a. BEGINNING DATE OF RFPnPTInIG PERIOD 8.b. ENDING DATE OF REPORTING PERIOD
4P
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 code.
Y~ 1(9 1/
ignature of ca idate date s' f political treasurer date
11. WITNESS SIGNATURE - l
va V_
signature of wit ss date
signature of ss date
12. SUMMARY 2
a. BALANCE ON HAND LAST REPORT $ IxI5.. 7.J
b. TOTAL RECEIPTSTHIS PERIOD l0'? _b0
c. TOTAL DISBURSEMENTS THIS PERIOD -:a-•~:...,,..........$ Q
7 70- 72
d. BALANCE ON HAND (12.a. plus 12.6. minus 12.c.)
e. TOTAL LOANS OUTSTANDING t.~............. $
"Pill -
149018
ci 0
f. TOTAL OBLIGATIONS OUTSTANDING .......j $
rf Cr+
SS-1109 (Rev. 2/06) ~'CJ z 4 4~ Page 1 of RDA 1159
SUMMARY PAGE - CANDIDATE
13. NAME OF CANDIDATE OR COMMITTEE (In Full) 14. REPORT COVERING THE PERIOD
~Eu, CS FROM: 59 .8 T0: 55111,;
RECEIPTS
15. CONTRIBUTIONS (other than loans and interest)
a. Unitemized Contributions ($100 or less from each source this period) $ «J`✓ Gb
b. Itemized Contributions (over $100 from each source this period) $ '.%bo • 00
c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ ~Jr DD
16. LOANS RECEIVED THIS REPORTING PERIOD $ 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)
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 $ 0
21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ O
22.IN-KIND CONTRIBUTIONS
a. Unitemized in-kind contributions ($100 or less from each source this period) $ d
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.) $ O
23. OBLIGATIONS
a. Unitemized Obligations Outstanding $100 or less each $ CS
b. Itemized Obligations Outstanding (Over $100 each) $ 0
c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 12.f.) $ Q
1 SS-1133 (Rev. 4/02) Page of
ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE
1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD
/Kc tvL$ FROM: T0: ~3t /c
Amount
3. TOTAL ITEMIZED CAMPAIGN CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) Q
4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED CONTRIBUTION (contributions totaling more than $100 from any contributor)
First Name Middle Name Contribution Received For: Amount of Contribution
Last Name1Or~nization Name Primary Election ❑ General Election
Address ❑ Runoff (Local Elections Only) 5`00.00
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
First Name iddle 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 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.) 500-60
(If this is the last page of contributions, this amount must be shown in item 15b. of summary.) Chi
W SS-1131 (Rev. 2/06) Page of RDA 1159
ITEMIZED STATEMENT OF IN-KIND CONTRIBUTIONS - CANDIDATE
1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD
FROM: TO:
Amount
3. TOTAL ITEMIZED 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 8100 from any contributor during the period)
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-Kind 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 In-Kind 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 NamelOrganization Name
❑ Runoff (Local Elections Only)
Address Date of In-Kind 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 In-Kind 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 In-Kind Contribution Aggregate this Election
city State Zip Code Description of In-Kind 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.)
Is W
SS-1128 (Rev. 2/06) Page of 1159
RDA
:e`r
ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE
1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD
FROM: ::::fm ount
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 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 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.)
5 SS-1129 (Rev. 4/02) Page of RDA 1159
ITEMIZED STATEMENT OF LOANS - CANDIDATE
1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD
FROM: TO:
3. COMPLETE THE APPROPRIATE 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 Payments (End of Period)
Last Name/Organization Name
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 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
First Name Middle Name First Name 77777
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
(Total loans received should also be shown in item 16. on summary page.) (Beginning of Period) Received Payments (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.)
4) SS-1132 (Rev. 4/02) Page of RDA 1159
i
ITEMIZED STATEMENT OF OBLIGATIONS - CANDIDATE
FCOMPLETEE NDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD
FROM: T0:
HE APPROPRIATE ITEMS FOR EACH ITEMIZED Outstanding Balance Debt Incurred Payments Outstanding Balance
obligations totaling more than $100 owe d to any (Beginning of Period) This Period This Period (End of Period)
at the end of the reporting period)
Flrst Name Middle Name
Last Name/Business Name
Address
City State Zip Code
Description of Obligation
Flrst Name Middle Name
Last Name/Business Name
Address
City State Zip Code
Description of Obligation
First Name Middle Name
Last Name/Business Name
Address
City State Zip Code
Description of Obligation
F Name Middle Name
amelBusiness Name
ss
City Stat e Zip Code
Description of Obligation
First Name Middle Name
Last Name/Business Name
Address
City State Zip Code
Desc ptionofobligation
4. TOTALS
(Total from Outstanding Balance - (End of Period) column must also be shown
in item 23b. on summary page.)
10 SS-1127 (Rev. 4/02) 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:
Candidates Name: /U ~~~✓~s
Candidates Position: 0e6,~~
Residential Address: lie? 7 s'L -1-vGD
City: X/Col)~ State: TN Zip: 3 7 7e5l,/
I hereby state that I meet the above qualifications for exemption and am
therefore exempt from filing financial disclosure statements.
Candidates Signature bate
ej, 74__/
Witness's S nature 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.
RECEIVED
APR 15 2oi~
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RECEIVED
AME) ,W.
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 2-10-101, 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 orcommittee:
` 3. Candidate e-mail address;
3~/3 E' .C u~i
.Car pa gn Address and Phone:
City State Zip Code e Phone
ne
SSA 4
Home Address and Phone (if different th m
4 abovCity
6.66 ce Sought (lnclude dlstrlct number, if applicable) 7. Party Affliction B. Election Year
G, A-
9. Treasurer Name: 10. Treasurer e-mail address:
11. Treasurer Address and Phone:
City State Zip Cade Phone
12. Candidate an Treasurer signal re (WI signatures must be witnessed. Treasurer cannot witness candidate's signaturej:
Signature of Candidate Signature of Treasurer
Signature of WI ness Signature of Witness
* Registry of Election Finanoo
SS-1120 (rev 10/2010)