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Lail, Holden CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 12.a. NAME OF CANDIDATE OR COMMITTEE tot. 3. ELECTION DATE 2.b. IF COMMITTEE, NAME OF CANDIDATE -1-A bIC~eQ ; L 1. moo/ 4.a. CAMPAIGN ADDRESS AND PHONE State Zip Code Phone Street or Rural Route City 8 Rl~.►.~r~ j~r,~ „c~-~`,~~ rv, m 37 ~'C~ • 9Y'!-G 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) State Zip Code Phone Street or Rural Route City 5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) 141 Ss•r he, r D 0- q f A 7. CATEGORY OR REP~T (Check one)❑ ❑ ❑ ❑ MIDD❑YEAR YEAR❑-END FIRST SECOND THIRD FOURTH PRE- PRE- DING DATE OF REPORTING PER SUPPLEMENTAL SUPPLEMENTAL QUARTER QUARTER QUARTER QUARTER PRIMARY 8.a. BEGINNING DATE OF REPORTING PERIOD 9. (Check one) a. 0-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. [/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. date signature of political treasurer date fcsignature of candidate 11. WITNESS SIGNATURE date signature of witness date nature of witness 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ b. TOTAL RECEIPTSTHISPERIOD .............................................................rti~ c. TOTAL DISBURSEMENTSTHIS PERIOD $ d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) $ Ff.__ TOTAL LOANS OUTSTANDING $ TOTAL OBLIGATIONS OUTSTANDING $ Page 1 of RDA 1159 SSA 109 (Rev. 2106) FINANCIAL DISCLOSURE STATEMENT EXEMPTION Pursuant to TCA S 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: Candidate's Position: Residential Address: N LA) I CX City: S~ `~5 4 State: TN Zip: 37 I hereby state that I meet the above qualifications for exemption and am therefore exempt from filing financial disclosure statements. 4/1 Candidate's Signature Date 411ob/ i 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. Q - 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. D'ate/: 2. Name of Candidate or Committee: 3. Candidate e1-mail address: - N ~q I H Lck: 0:) C~~qf_t, _ 4. Campaign Address and Phone: City State Zip Code Phone f-~Ct 3vS6 ~Avw_)ic-k Dr. ~CoS- eincQsj, L[ e Tu 3 7~ 3 ~ ~~~-p84'S S. Home Address and Phone (if different than item 4 above): City State Zip Code Phone CA 6.Office Sought (include district number, if applicable) 7. Party Affliation 8. Election Year 9. Treasurer Name. 10. Treasurer e-mail address: U G LC., . I R_LCc . ) c.~ -7 Gc) 0-o I , i"O tom. 11. Treasurer Address and Phone: City State Zip Code Phone 4[ Y\,w ck ~J ~7f : e- s __Y V, [Le TN 3~73~ gW - 12. Candidate and Treasurer Signature (both signatures must be witnessed. Treasurer cannot witness candidate's signature): Signature of Candidate Signature of Treasurer 4Signature of Witness Signature of Witness Registry of Election Finance 6 " * f` SS-1120 (rev 1012010) ' ' v i►r ►iI 1 Y D °Zl tl l1L r CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 12.a. NAME OF CANDIDATE OR COMMITTEE jt, ( / C) N D lc en f ~cx r C U M N~~ 5 S i ski 2.b. IF C MITTEE, NAME OF CANDIDATE 3. ELECTION DATE 16- . 5 Z-o r 0 4.a. CAMPAIGN ADDRESS AND PHONE Street or Rural Route City State Zip Code Phone 36F W nJwi_IL ~r,v~~ 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone 5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) J 51r ( cc 7. CATEGORY OR REPORT (Check one) ~ ❑ FIRST SEC1:1 1:1 Cl El OND THIRD FOURTH PRE- IPRE- 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 C)vtl, , ~~,~t Zo l C 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. [/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. Ju h9 )f v ~1 ~G a q ~Zo r'U signature of candidate date signature of political treasurer date 11. WITNESS SIGNATURE 7 9-i y -719- 10 signs u of witness date signat of witness date 11 ~.p 12. SUMMARY .O Q o, RECEIVED r 91'. 0 a. BALANCE ON HAND LAST REPORT tu, ...................k.............. $ AUG 0 2 2011 $ p o b. TOTALRECEIPTS THIS PERIOD .............................R .................................a,.. 11111 "Cou"'Y• <o ' AECTION $ c. TOTAL DISBURSEMENTS THIS PERIOD c^.~ ...............~a...~ ~0.................. zNb --0 - d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c. $ e. TOTAL LOANS OUTSTANDING $ f. TOTAL OBLIGATIONS OUTSTANDING $ SS-1109 (Rev. 2/06) Page 1 of RDA 1159 SUMMARY PAGE - CANDIDATE 13. NAME OF CANDIDATE OR COMMITTEE (In Full) 14. REPORT COVERING THE PERIOD FROM:S, ( ~1 ~ IO TDJ« 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) . $ 7 D • o O c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ 0 0 16. LOANS RECEIVED THIS REPORTING PERIOD D 17. INTEREST RECEIVED THIS REPORTING PERIOD LJ 18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.) ()D 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) P r'_1) c~ s-s $ 33t o° ew5e& 00 EC's J $331o. av $ $ $ $ $ $ Total of Expenditures ($100 or less each payee) $ b. Itemized Expenditures Over $100 each payee this period) $ ;7, 9~{ D 0 c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ a~1 • ~o 20. LOAN REPAYMENTS MADE THIS PERIOD - O 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ 9- 00 22.IN-KIND CONTRIBUTIONS a. Unitemized in-kind contributions ($100 or less from each source this period) $ - C~ 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) $ SS-1133 (Rev. 4102) Page of ITEMIZED STATEMENT OF LOANS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD /cYe'vi r1 OM: f l a T0: Zj l~ 3. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED LOAN (loans totaling more than 5100 from any source du g 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 [3 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 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 -1 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 NamelOrganization 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 bans) 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 Pa ments 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.) Aft, SS-1132 (Rev. 4/02) Page of RDA 1159 `QV ITEMIZED STATEMENT OF OBLIGATIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM:,)k ioyD TO:jk z~ Zat~ 3. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED Outstanding Balance Debt Incu d 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 Zip Code Description of Obligation First Name Middle Name Last Name/Business 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 4. TOTALS (Total from Outstanding Balance - (End of Period) column must also be shown _ - - - - - - Z in item 23b. on summary page.) 4) SS-1127 (Rev. 4102) Page of RDA 1159 ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD 14Z) I d e- kl-~ 1, q; f FROM: J 2oz T0:. j :2, 7, I D 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 MlddleName Contribution Received For: Amount of Contribution La Name/Organization Name ❑ Primary Election ,f General Election Addre❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer C' C. First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election 0 General Election C t' Al,-C". l~i~ tin t u~ C !3~ CUrt.( CL . Address ❑ Runoff (Local Elections Only) S U OL City State Zip Code Date of Contribution Aggregate This Election Occupation Employer 2.S c - c First Name iddleName Contribution Received For: Amount of Contribution as ame rganiza ron ame ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Cade Date of Contribution Aggregate This Election Occupation Employer First Name Middle Name Contribution Received or. Amount Contribution Last Name/Organizatlon 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 paged additional pages of this form are used.) (If this is the last page of contdbutions, this amount must be shown in item 15b. of summary.) (9 SS-1131(Rev. 2106) Page of RDA 1159 ITEMIZED STATEMENT OF IN-KIND CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD Nf: ,l- FROIt I Vic, -C TO: J c, Z q Zo fd moun 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 $100 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 NamelOrganization Name ❑ Runoff (Local Elections Only) Address Date of in-KGnd Contribution Aggregate this Election city Slate 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 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 Dale 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 ofIn-Kind Conbibution Aggregate this Election City State Zip Code Description of In-Kind Contribution p n m yer Occu 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 most be shown in item 22b. of summary.) SS-1128 (Rev. 2106) Page of RDA 1159 ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD F FROM: TO: 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 Last Name siness Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Nam usiness Name , 2 r 5 A u n Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last NameBusiness Name f 33 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.) v (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