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Blackstock, Benny CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candldate Committees 1. DATE OF REPORT 12.a. NAME OF CANDIDATE OR COMMITTEE July 8, 2014 Benny Blackstock 2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE May 6, 2014 4.a. CAMPAIGN ADDRESS AND PHONE Street or Rural 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 1128 N Sequoyah Drive Friendsville TN 37737 865-216-1540 5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) Blount Count Commissioner - District 7 - Seat A Nancy Blackstock 7. CATEGORY OR REPORT (Check one) 1:1 1:3 0 1:1 1:1 171 0 FIR SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END DARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8. a. BEGINNING DATE OF REPORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIOD April 27, 2014 June 30, 2014 9. (Check one) a. 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.) i. Per 053 1---1----.06 CAMPAIGN LOANS This is to advise that the outstanding loan balance of $298.51 will not be repaid and that it shall be considered a contribution to the campaign. This is the final Financial Disclosure Statement for Candidate, Benny Blackstock. There is not a balance on hand and all outstanding obligations have been paid. The unpaid loan balance of $298.51 has been contributed to campaign. Pny addi 'on actions a re quired or if other information is needed. 7-8-14 7-8-14 candidate date igna re of political treasurer date 11. WITNESS SIGNATURE 7-8-14 _X~& ~e~Zt~,UlLQ~c~. /~6ti 7-8-14 signature of witness date signature of witness date 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ 273.44 b. TOTAL RECEIPTSTHIS PERIOD 298.51 273.44 c. TOTAL DISBURSEMENTS THIS PERIOD $ d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) $ 0 e. TOTAL LOANS OUTSTANDING $ 0 f. TOTAL OBLIGATIONS OUTSTANDING $ 0 i CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT I2.a. NAME OF CANDIDATE OR COMMITTEE July 8, 2014 Benny Blackstock 3. ELECTION DATE 2.b. IF COMMITTEE, NAME OF CANDIDATE May 6, 2014 4.a. CAMPAIGN ADDRESS AND PHONE State Zip Code Phone Street or Rural Route City 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone TN 37737 865-216-1540 1128 N Sequoyah Drive Friendsville 5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate n ) Nancy Black stock 7 -Seat A Blout Count Commissioner - District ❑ ❑ ❑ (Ch ck 7. CATEGORY OR REPORT e one ❑ ❑ ❑ PRE- MIDYEAR YEAR-END FIRST SECOND THIRD FOURTH PRE- UARTER QUARTER QUARTER QUARTER 8.b. IAERNDING DATE OF RE ORTINS PEP R EMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF REPORTING PERIOD April 27, 2014 June 30, 2014 9. (Check one) d 5 tunes ctotal ampaign is or mptt for this period. (Complete contrib12d., 12e. utions (including in-kind) received total $1,000 or less AND expendi- 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. [/we do solemnly swear or affirm that the information contained in this campaign financial disclosure report is true and that this report is an accurat ccounting of campaign contributio and expenditures required to be reported by the candidate committee by the Campaign internal revenue code. expended for the personal financial Fin of theclcoand d Actor d any all ye /w npowear liticalrpuaffirm that no campaign rpose as defined by the contributions have been b __L-LL 4_ 7-8-14 ignat a of political treasurer date signatur of candidate date 11. WITNESS SIGNATURE 7 c c ~~lA l~Gt~~~~ - -8-14 7-8-14 7-8-14 date signature of witness date signature of witness 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ 273.44 $ 298 .51 see attached statement b. TOTAL RECEIPTSTHIS PERIOD 273.44 c. TOTAL DISBURSEMENTSTHIS PERIOD $ $ 0 d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) e. TOTAL LOANS OUTSTANDING 0 F f. TOTALOBLIGATIONS OUTSTANDING $ CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 12.a. NAME OF CANDIDATE OR COMMITTEE April 1, 2014 Benny Blackstock 3. ELECTION DATE 2.b. IF COMMITTEE, NAME OF CANDIDATE May 6, 2014 4.a. CAMPAIGN ADDRESS AND PHONE State Zip Code Phone Street or Rural Route City 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) State Zip Code Phone Street or Rural Route City 1128 N Sequoyah Drive Friendsville TN 37737 865-216-1540 5. OFFICE SOUGHT (include district number, if applicable) =aann AL TREASURER (may be candidate) Blount County Commissioner - District 7 - Seat A ck 7. CATEGORY OR REPOR T (Check one) ❑ FIRST SEND THIRD FOURTH PR - 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 April 1, 2014 April 26, 2014 9. (Check one) a. 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. ltwe 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 nd expenditures required to be reported by the candidate committee by the Campaign Fina a Disclosure Act. d ' ally I/we s ar or affirm that no campaign contributions have been expended for the personal financial of the candida r r yo er no olitical purpose as defined by the federal internal revenue code. 4-28-14 41 r '4 64 4-28-14 date si atur f political trea I date signatu o candidate 11. WIT SS SIGNATURE CUwI~G 4-28-14 signature of witness date signs re of witness date SUMMARY $ 559.24 a. BALANCE ON HAND LAST REPORT . -0- b. TOTAL RECEIPTSTHIS PERIOD $ 285.80 c. TOTAL DISBURSEMENTSTHISPERlOD $ 774 44 d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) . $ $ 500 00 Ee. TOTAL LOANS OUTSTANDING 71.95 . TOTAL OBLIGATIONS OUTSTANDING Page 1 of 1_ RDA 1159 SS-1109 (Rev. 2106) CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 2.a. NAME OF CANDIDATE OR COMMITTEE April 1, 2014 Benny Blackstock 2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE May 6, 2014 4.a. CAMPAIGN ADDRESS AND PHONE Street or Rural 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 1128 N Sequoyah Drive Friendsville TN 37737 865-216-1540 5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) Blount County Commissioner - District 7 - Seat A Nancy Blackstock 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 DATE OF REPORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIOD February 27, 2014 March 31, 2014 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 cam aign contributions and expenditures required to be reported by the candidate committee by the Campaign Fi cial Disclosure ct. ditio Ity swliear or affirm that no campaign contributions have been expended for the personal financial efit of the candi t fora otheIr npotical purpose as defined by the federal internal revenue code. 4-2-2014 a"i~~ ~)l ~1 is 4-2-14 signs re of candidate date sign ure q political tress rer date i U 11. V NESS SIG~N>ATURE 4-2-14 4-2-14 signature of witness date gnature of witness date 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ -0- b. TOTAL RECEIPTS THIS PERIOD `i' $ 1,724.77 c. TOTAL DISBURSEMENTSTHIS PERIOD $ 1.165.53 d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) $ 559.24 e. TOTAL LOANS OUTSTANDING $ 500.00 f. TOTAL OBLIGATIONS OUTSTANDING $ 71.95 9D SS-1109 (Rev. 2106) Page 1 of 7 RDA 1159 SUMMARY PAGE - CANDIDATE 13. NAME OF CANDIDATE OR COMMITTEE (In Full) 14. REPORT COVERING THE PERIOD Benny Blackstock FROM: 2-27.14 TO: 3-31-14 RECEIPTS 15. CONTRIBUTIONS (other than loans and interest) a. Unitemized Contributions ($100 or less from each source this period) $ 100.00 b. Itemized Contributions (over $100 from each source this period) $ 450.00 c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ 550.00 16. LOANS RECEIVED THIS REPORTING PERIOD 500.00 17. INTEREST RECEIVED THIS REPORTING PERIOD $ -0- 18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.) $ 1,050.00 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) printing $ 52.47 postage $ 10.20 signage $ 9.28 donation $ 100.00 signage $ 17.17 $ $ Total of Expenditures ($100 or less each payee) $ 189.12 b. Itemized Expenditures Over $100 each payee this period) $ 976.41 c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ 1,165.53 20. LOAN REPAYMENTS MADE THIS PERIOD $ -0- 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ 1.165.53 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) $ 602.82 c. TOTAL IN-KIND CONTRIBUTIONS RECEIVED THIS PERIOD (add 22.a. and 22.b.) $ 602.82 23. OBLIGATIONS a. Unitemized Obligations Outstanding ($100 or less each) $ 71.95 b. Itemized Obligations Outstanding (Over $100 each) $ c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 121) $ 71.95 SS-1133 (Rev. 4/02) Page 2 of 7 ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD Benny Blackstock FROM: 2-27-14 TO: 3-31-14 Amount 3. TOTAL ITEMIZED CAMPAIGN CONTRIBUTIONS FROM PRECEDING PAGE (enter $0lf first itemized page) 1-0- 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED CONTRIBUTION contributions totaling more than $100 from a contributor FxstName Middle Name Contribution Received For: Amount of Contribution William H tastName/Organizatim Name Qj Primary Election ❑ General Election 250.00 Reed Address ❑ Runoff (Local Elections Only) PO Box 3306 City stale ZIP Code Date of Contribution Aggregate This Election Knoxville TN 37927 Occupation 3-10-14 250.00 President Employer Skyline Transport FistName Middle Name Contribution Received For: Amount of Contribution William H Last Name/Organization Name MPrimary Election ❑ General Election McCall 200.00 Address ❑ Runoff (Local Elections Only) 9041 Executive Park Drive, Suite 250 City State Zip Code Date of Contribution Aggregate This Election Knoxville TN 137923 Occupation 3-10-14 Financial Advisor, Managing Director 200.00 Employer Ameriprise Financial FtistName IeName Contribution Received For: Amount of Contribution as ganva 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: mount o 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 (Carty (onward 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.) 450.00 0) SS-1131(Rev. 2/06) Page 3 of 7 RDA 1159 ITEMIZED STATEMENT OF IN-KIND CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD Benny Blackstock FROM: 2-27-14 TO: 3-31-14 mount 3. TOTAL ITEMIZED IN-KIND CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) -0- 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 In-Kind Contribution Received For: Value of In-Kind Contribution Tom ® Primary Election ❑ General Election Last Name/Organiza Hatrhpr tionName ❑ Runoff (Local Elections Only) 453.27 Address 128 Temple Road Date of In-Kind ConfiMrfion 3-3-14 Aggregate this Election city Maryville "'TN 'PV804 Description ofln-KindContrilution Occupation Employer Campaign Signs Circuit Court Clerk Blount County Tennessee First Name Middle Name In-Kind Contribution Received For: Value of In-Kind Contribution Tom ® Primary Election ❑ General Election Last Name/Organization Name 149.55 Hatcher ❑ Runoff (Local Elections Only) Address Date of In-Kind Contribution Aggregate this Election 128 Temple Road 3-8-14 60282 City State Lp Code Description of In-Kind Contribution Maryville TN 37804 Occupation Employer Meet and Greet Circuit Court Clerk Blount County Tennessee Fist Name Middle Name In-Kind Contribution Received For: Value of In-Kind Contribution ❑ Primary Election ❑ General Election Last Name/Organizabon Name ❑ Runoff (Local Elections Only) Address Date of In-Kind Contribution Aggregate this Election city state ZipCode Descdptbnof In-Kind Contribution Occupation Enooyer Fist 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 ZipCode Description of In-Kind Contribution Occupation Employer Fist Name MiddleName 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 Zrp Code Description of I"ind Contribution upa n LrinploYer 5. TOTAL ITEMIZED IN-KIND CONTRIBUTIONS (Carty forward to item 3. of next page if additional pages of this form are used.) 602.82 (n 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 4 of 7 RDA 1159 ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD Benny Blackstock FROM:2.27.14 TO: 3-31-14 mount 3. TOTAL ITEMIZED CAMPAIGN EXPENDITURES FROM PRECEDING PAGE (enter $0 if first itemized page) -0- 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 Campaign Yard Signs 453.27 ProSi n Address 2355 6 Mile Road city State Zip Code Maryville TN 37803 First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Nameausiness Name ProSign Campaign Signs 373.59 Address 2355 6 Mile Road City State Zip Code Maryville TN 37803 First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Law's Brickmill Market and Deli Address Meet and Greet 149.55 103 Brick Mill Road City State Zip Code Maryville TN 37801 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.) 976.41 Agalk SS-1129 (Rev. 4102) Page 5 of 7 RDA 1159 ITEMIZED STATEMENT OF LOANS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: TO: Benny Blackstock 2-27-14 3-31-14 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 Benny (Beginning of Period) Received Payments (End of Period) Last Name/Organization Name -0- 500.00 -0- 500.00 Blackstock Address Loan Received For. Date of Loan 1128 N Se uo ah Drive IN Primary Election ❑GeneralElection 2-28-14 city State Zip Code Friendsville TN 37737 ❑ 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 Middle Name Last Name/Organization Name Last Name/Organization Name Address Address city Stale Zip Code city State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding 4. Totals for al 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 balanceshould also be shown in item 12.e. on front page.) -0 500.00 -0- 500.00 AWL SS-1132 (Rev. 4102) Page 6 of 7 RDA 1159 ITEMIZED STATEMENT OF OBLIGATIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD Benny Blackstock FROM: 2-27-14 TO: 3-31-14 3. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED Outstanding Balance Debt Incurred Payments Outstanding Balance OBLIGATION (obligations totaling more than $100 owed to any (Beginning of Period) This Period This Period (End of Period) person/vendor at the end of the reporting period) First 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 Tip Code Description of Obligation First 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 First Name Middle Name Last Name/Business Name Address city state Zip Code Description of Obligation 4.TOTALS (Total from Outstanding Balance - (End of Period) column must also be shown in Rem 23b. on summary page.) SS-1127 (Rev. 4/02) Page 7 of 7 RDA 1159 o S-CEIVED -r~ 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 Committee: 3. Candidate e-mail address: 4. Campaign Address and Phone: City State Zip de Phone G ~d ~iJF /Zltr s ~J~c cf X773 % 6;~ -,2/.1 -/ssv S. Home Address and Phone (if d er than item 4 above): City State Zip Code Phone 6. Office Sought (include district number, if applicable) 7. Party Affliation 8. Election Year ~tuti, 'cy>~,►~ rs r~ - ~ rst ~y r f~tPa~a L,~ c~.~i~l n 9. Treasu r Name: 10. Treasurer e-mail address: NRnlc! 67~~ck pPnn 1~~55toc~ cc,-OCast. het 11. Treasu rAddress and Phone: City State Zip Code Phone F~ UG A ~~vf'ifwciss cJ,~~ r u~773 `JloS °~/~-(3q 12. Candid and Tre sur ig ature th s gnatures ust be witnessed. Treasurercan not witness candidate's signature): i~ S gnature of Candidate Signature of Treasurer Signature of Witness Signature of Witness Registry of Election Finance SS-1120 (rev 1012010)