Daly, Jamie i
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For State and Local Candidates
For Single-Candidate Committees
2.a. NAME OF CANDI ATE OR COMMITTEE !p`~
1. OF EPOF~T~ ~ ~ J 1"/ C ~ "K
3. ELECTION DATE
2.b. IF TTgg' NAME OF CA~tDATE~
4.a. CAMPAIGN ADDRESS AND PHONE Stag Zip ~ Code Phone
~~9
reef or Rural ute City 3-7-771 ! "q-j `2--
4.b. CANDIDATE'S HOME ADDRESS (if different h iy 4•a•) Zip Code ~~~e
Street or Rural Route W~ Wk / G, to 37 ` 9*7 /0 Y'~
<,M W
5. FFICE SOUGHT (include district number, if appli(cable) v~ 6. NAME OF POLITICAL TREASURER (may be candidate)
7. CATEGORY OR REPORT (Check one)
❑ El El FIR T SEND THIRD F TH PRE- pRE_ MID-YEAR YEAR-END
SUPPLEMENTAL
QUARTER QUARTER QUARTER Q TER PRIMARY DATE OF GENERAL SUPPLEMENTAL
~
8.a. BE INNIN o- ATE ORE PORTING PERIOD
9. (Check e) l~illJt
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.
aign conttributions and expenditueeslrequked t pbe reported by thelcandidateocomm'ttee by thetCampaPgn is an
F Ilw urate accemn ea
ounting of camp
acc
nancial Disclosure Act. Additionally, Ilwe swear or affirm that no campaign contributions have been expended for the personal financia
Fior any other nonpolitical purpose as defined by tZsiature eve a code.
benefit of the candidate or f
46
p I treas er da te
signature of candidate date
11. WITNE~SSIGNATURE
signature of witness date
signature of witness date
12. SUMMARY
11 i~D
$
. .
a. BALANCE ON HAND LAST REPORT
b. TOTAL RECEIPTS THIS PERIOD $ S49
Z. J
$
c. TOTAL DISBU RSEMENTS THI S PERI OD
$
d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.)
e. TOTAL LOANS OUTSTANDING
f. TOTAL OBLIGATIONS OUTSTANDING
SS-1109 (Rev. 2106) Page 1 of RDA 1159
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For State and Local Candidates
For Single-Candidate Committees
1. D T OF EPORT 2.a. NAME OE CANDIDATE OR COMMITTEE
2.b. IF COMMITTEE, NAME O CANDIDATE 3. ELECTION DATE
At6M;r '7, 2-0 /f
4.a. CAMPAIGN ADDRESS AND PHONE
Street or Rural Route City State Zip Code Phone
.4"C _9VOfr 6,N.. a"40U k rA! 37777 '777 - 9f z 7-
4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.)
Street or Rural Route City State Zip Code Phone
5. O Fl E SOUGHT (include district number, if a plicable) 6. NAME OF POLITICAL TREASURER (may be candidate)
Aff
7. CATEGORY OR REPORT (Check one)
FIRST SECOND it FOURTH P1:3 13 RE- PRE- MIDYEAR YEAR❑-END
QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL
8.a. BEGINNIN OF PORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIOD
,_7114 9. (Check on
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
benefit of the candidate or;for any other nonpolitical purpose as defined by the federal in al re nue code.
41 signature of candidate date sig ure of ' ical tre surer date
WITNESS SIGNATURE
Lai ~A :T- LL~~
signal a of witness date si a re of witness date
12. SUMMARY p
a. BALANCE ON HAND LAST REPORT $ O
b. TOTAL RECEIPTS THIS PERIOD
c. TOTAL DISBURSEMENTS THIS PERIOD $ 0 ! v. ,*3
d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) $ v i
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 ANDIDATE OR C MITTEE
L-1 2 20 i V Cti(jT JAN I(-- bAL
2.b. IF COMMITTEE, AME OF CANDIDATE 3. ELECTION DATE
J'A,~4 I& A-0 Uhf 7
4.a. CAMPAIGN ADDRESS AND PHONE
Street or Rural Route City State Zip Code Phone
~2N1 G S' ot~T ctj (~D(J~M1c C- TN -7
°!7~-~1 ~2v
4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.)
Street or Rural Route City State Zip Code Phone
OFFICES GHT (incl de district num e , if applicable) 6. NAME O POLITICAL TREASURER (may be candidate)
AV1 'CATEGORY OR REPORT (Check one)
FIRST SECON0 E] D THIRD FOURTH PRE- FE- MIDD❑YEAR YEAR❑-E
ND
QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENT SUPPLEMENTAL
8.a. BEGINNING DATE OF REPORTING PERIOD 8. b. ' ENDING DATE OF REPORTING PERIOD
A
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. Itwe 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, Itwe 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 ' mal re nue code.
signature of candidate date si ture dical tre surer date
11. WITNE ATU
signat tv witness date i nature of witne s date
12. SUMMARY ilz Q ° fo
a. BALANCE ON HAND LAST REPORT $ I .
b. TOTAL RECEIPTSTHIS PERIOD
c. TOTAL DISBURSEMENTS THIS PERIOD $
• d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) I~...j..q.. $
e. TOTAL LOANS OUTSTANDING $
.1 OQr ~S
f. TOTAL OBLIGATIONS OUTSTANDING . WLAA... $
4D cn
SS-1109 (Rev. 2/06) d ~0 Page 1 of RDA 1159
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For State and Local Candidates
For Single-Candidate Committees
~1
1. DATE OF REPORTI,~ I~ + I 2.a. NAME / lOF CANDIDATE 'c- Opo I~Q47T~~ ~ ~ le 6A-01
2.b. IF CO MITT E,,NV vA E OF CANDIDATE '1t-'/ C 3. ELECTION cDATE
4.a. CAMPAIGN ADDRESS AND PHONE
Street or Rural Route City State Zip Code Phone
20Q Cl_ L-AJ Tiv' 3'7`7,17 qT 7-5
4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.)
Street or Rural Route City State Zip Code Phone
5. ~FFICE SOUGHTC'(include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may~op candidate
LDU~rr ouui G'~5 ifs,u~ t
7. CATEGORY OR REPORT (Check one) E] 1:1 1:1 ID 1:1 El
FIR SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR❑-E
ND
QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL
8.a. BEGINNING DATE OF REPO_nNG PERIOD 8.b. ENDING DATE OF REPORTING PERIOD
11
q1tck -5 1 -2,0 1'+
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 a candidate committee by the Campaign
Financial Disclosure Act. Additionally, I/we swear or affirm that no campaign contribution ve been expended for the personal financial
benefit of the candidate or for any other nonpolitical purpose as defined by the federal i al reven code.
L
signature of candidate date ig a of polhica,06asurej date
11. WITNESS SIGNATURE
signature of witness date signature of witness date
12. SUMMARY
a. BALANCE ON HAND LAST REPORT $
b. TOTAL RECEIPTS THIS PERIOD $ f ,
'
c. TOTAL DISBURSEMENTS THIS PERIOD $ Z I
d. BALANCE ON HAND 12.a. plus 12.b. minus 12.c. r d
e. TOTAL LOANS OUTSTANDING $
f. TOTAL OBLIGATIONS OUTSTANDING $ O
Almik
SS-1109 (Rev. 2106) Page 1 of -7-- RDA 1159
SUMMARY PAGE - CANDIDATE
14. REPORT COVERING THE PERIOD
13 NAME OF CANDIDATE O COMMITTEE (In Full)
FROM:
RECEIPTS
15. CONTRIBUTIONS (other than loans and interest) ca
a. Unitemized Contributions ($100 or less from each source this period) $
77
b. Itemized Contributions (over $100 from each source this period) 7 7
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 PERT .
18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.)
DISBURSEMENTS
19. EXPENDITURES (other than loan payments)
a. Ex enditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage, gasoline)
Q 10 t AJ(r vis-rA k-l e, $ ft 4-7
.7 q0
l l-5 ~~Ih E $
$
$
$
$
$
$
Total of Expenditures ($100 or less each payee) $
dZ Z~ Z
b. Itemized Expenditures (Over $100 each payee this period) $ / ~tivZ9
c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) O
20. LOAN REPAYMENTS MADE THIS PERIOD $
I46Z,7~
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) $ O
C. TOTAL IN-KIND CONTRIBUTIONS RECEIVED THIS PERIOD (add 22.a. and 22.b.)
FIAATIONS d Obligatio
$
ns Outstanding ($100 or less each)
Obligations Outstanding (Over $100 each) $
C. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 121) $ D
Page ~ of _ 7
- SS-1133 (Rev. 4102)
i
ITEMIZED STATEMENT OF LOANS - CANDIDATE
1. NAME OF CANDIDATE OR COMMITTTEE, 2. REPORT COVERING THE PERIOD
Co 1~' v ,4i-(- 6 wti4 l l~ F.R~OM: Tpr
3. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED LOAN (loans totaling more than $100 from any source urin the period) 9 )
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 an Rece ad Fo
Date of Loan
Prim El General Election
Gty S Zi Code
G off (Local Elections Only)
st All En ers or uarantors 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/Organ7-ab.nNar
e
Addr
ess
Address
city State Zip Code City
State Zip Coda
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
Slate 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 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
Amount Guaranteed Outstanding mount Guaranteed Outstanding
State 40-;~X
4. Totals for all Loans (complete on last page of itemized loans
(Total loans received should also be shown in item 16. on summ Outstanding Loan Balance Loans Loan Outs(Total loan payments should also be shown in item 20. on summary page.) I (Beg innin of Period Received Pa menu (End M (total outstanding loan balance should also be shown in item 12.e. n front e.)
)
Page)
SS-1132 (Rev. 4102) Page_ of
RDA 1159
ITEMIZED STATEMENT OF OBLIGATIONS - CANDIDATE
PI.N OF CANDIDATE OR CO TT 2. REPORT COVERING THE PEOD
eIC FROM: TO: PLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED Outstanding Balance Debt Incurred Payments Outstanding Balance
ATION (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 Last NamelBusiness Name
Address
city e
Description of Obligation
First Name Middle Name
-Last Narneffusiness Name
Address
city state Zip Coda
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 --t"Idle 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 I~ O v r _
in item 23b. on summary page.)
A2k
SSA 127 (Rev. 4102) Page of RDA 1159
l
ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE
1. NAM N DATf 2. REPORT IjCOeMITT,ET- AL`` FROM: ~ERITOT ~I
L W lr r Amount
3. TOTAL ITEMIZED CAMPAIGN CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 if first itemized page) 0
4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED CONTRIBUTION contributions totaling more than $100 from an contributor
First Name L / Middle,A~arpe „ , r Contribution Received For. Amount of Contribution
Last Name/ !5 Narpe Primary Election ❑ General Election
address+U 1,*Vk [:1 Runoff (Local Elections Only)
City M` / `W/"A- s(afrr' ZipCo5-7.'7'P Date of Contribution Aggregate This Election
occupation O 'e- U1
Employer
First a e~C MiddJ rpe Contribution Received For: Amount of Contribution
Last Na iniT me Primary Election ❑ General Election
qzlo '7
Address ❑Runoff (Local Elections Only) 7/
City l~ floc ,1l
' - LpQ5T Date of Contribution Aggregate This Election
Tj?)'7-
Occupawe,
EmployV-
FirstName ~ iddleN Contribution Received For: Amount of Contribution
s a ¢a name Primary Election ❑ General Election
Co o r( 2
addre; „ _ e q~ ~.r~~ '1 ❑ Runoff (Local Elections Only)
City Shate~~ r Zip QDde Date of Contribution Aggregate This Election
L-mpioyer
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.)
dwk
SS-1131(Rev. 2/06) Page J7 of -7 RDA 1159
ITEMIZED STATEMENT OF IN-KIND CONTRIBUTIONS - CANDIDATE
2. REPORT COVERING THE PERIOD
1. NAME F CANDIDATE OR COMMITTEE F Uaq- ti TO: ,7
G, moun O
3. TOTAL ITEMIZED IN-KIND CONTRIBUTIONS FROM PRECEDING PAGE (enter $0 ff first itemized page)
ling
COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED IN-KIND CONTRIBUTION (tn-kind contributions totamore than 5100 from any contributor
of In hind Contribution
Middle Name In-Kind Contribution Received For.
First Name ❑ Primary Election ❑ General Election
Last NamelOrganizationName ❑ Runoff (Local Elections Only)
Aggregate this Election
Date of In-Kind Contribution
Address
state zip code Description of in-Kind Contribution
City
occupation Employer
Value of In-Kind Contribution
mmw~ Middle Name In-Kind Contribution Received For.
First Name ❑ Primary Election ❑ General Election
Last Name/Organization Name ❑ Runoff (Local Elections Only)
Aggregate this Election
Dale of In-land Contribution
Address
State Zip Cade Description of In-Kind Contribution
City
occupation Employer
Value of In-Kind Contribution
In-Kind Contribution Received For
First Name Middle Name Primary Election ❑ General Election
Last NamelOrganizationName ❑ Runoff (Local Elections Only)
Aggregate 1hisElection
Date of In-land Contribution
Address
state Zip Code Description of In-land Contiftbon
City
TFE~ pabon
Value of In-Kind Contribution
Middle Name in-Kind Contribution Received For.
First Name ❑ Primary Election [3 General Election
Last Nameforganizati on Name 0 P.unoff (Local Elections Only)
Aggregate this Election
Date of In-Kind Contribution
Address
State Zip Code Description of In-land Contribution
City
Occupation Employer
Value of In-Kind Contribution
Middle Name In-Kind Contribution Received For:
First Name ❑ Primary Election ❑ General Election
Last NamelOrganizationName ❑ Runoff (Local Elections Only)
Aggregate this Election
Date of In-Kind Contilbution
Address
Slate Zip Code Description of In-land Contitbution
City
oocupauon
5. TOTAL ITEMIZED IN-KIND CONTRIBUTIONS
(Carty forward to item 3. of next paged additional pages of this form are used.)
(If this is the last page of in4dnd contributions, this amount must be shown in item 22b. Of summary.) Page of RDA 1159
SSA128 (Rev. 2106)
ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE
15
2. REPORT OVERING THE PERIOD
1. NAME OF CAN~~ R~ rl111 FROM: - - Etk
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) Amount of Expenditure
Middle Name Purpose of Expenditure First Name
1
Last Name/Business Name
Address ~ 546AJ5 i/
~r~%(~
City r A l l ~ liFS S Zip Jet -
r ` Purpose of Expenditure Amount of Expenditure
7 Middle Name
First Name
Lasy~q B s Name
Add
~N~tac-rte~v
4430
Gty~~'~ gta~~ Zi Code
TT,`n
Purpose of Expenditure Amount of Expenditure
First Name Middle Name
Last NamelBusiness Name
Address
City State Zip Code
Purpose of Expenditure Amount of Expenditure
First Name Middle Name
Last =Name/Bussinesssame
Address
City State P Code
Purpose of Expenditure Amount of Expenditure
First Name Middle Name
Last Name/Business Name
Address
City state Zip Code
Purpose of Expenditure Amount of Expenditure
First Name Middle Name
Last Name/Business Name
Address
City State Zip Code
5. TOTAL ITEMIZED EXPENDITURES f ~j 2
(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.)
Page / of 7 RDA 1159
AMIL
SS-1129 (Rev. 4102)
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:
Candidates Position: CO C,00 M I Ay0 d T (0 -
Residential Address: (in v ~ It-514 '0
~y
City: <S /Ifs State: TN Zip: 7
I hereby state that I meet the above qualifications for exemption and am
therefore exempt from filing financial disclosure statements.
Candidate Signature Date
&A a4.:t2
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.
- , Mai 3l ~1
IVd ~
e V % RECEIVED 1
/ I
f ^q4
MMM
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 2-10-10 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 theiroriginal Appointment of Political Treasurer statement ONLY with
their county election commission.
1.
Date: 2. N e of Candate or Committee: 3. Candidate ;7;
l address: 4 AM 4. Campaign Address and Phone: City State Zip Code Phone
42Z 6 -S m coT b'ruF rxi 3-7177 F6-11-q77 - 9P 2
S. Home Address anted Phone (if different than item 4 above): City State Zip Code Phone
6. ice Sought (include district number, if applicable) 7. Party Affliation 8. Election Year
Arr CO (WI-1 C&/U 410513 t0A)16
6, S I-OU CT- P) 96~ Wf N
9. Treasurer Name:
10. Treasurer a-mail address: L
~~X Zw d)
11. Treasurer Address and Phone: City state Zip Code Phone
di
~2x G t4Ac~l C .I,E ~gtcIS 1L,(C- -7~ 1777 5/517 "7-g~2L
12. Candidate and Treasurer Signature (both signatures must be witnessed. Treasurer cannot witness candidate's signature):
riSignature of Candidate ignature of Treasurer
0~
r
Signature of Witness / Signature of Witness
V
Registry of Election Finance
SS-1120 (rev 10/2010)