Blount County Republican Women
APPOINTMENT OF POLITICAL TREASURER
For Multi-Candidate Committees (PACs)
INSTRUCTIONS
This form must be used to appoint a political treasurer as required by the Campaign Financial Disclosure Act (T.C.A. §2-10-105)
for multi-candidate committees (PACs). No funds may be received or expended for a future election until a political treasurer has
been appointed. A new form must be filed if the treasurer is changed.
Committees that make contributions only to candidates for state public office must file this form and a $100 annual fee with the
Registry of Election Finance, 404 James Robertson Parkway, Suite 104, Nashville, TN 37243-1360. Committees that make
contributions only to candidates for local public office must file with the local county election commission in the county where the
contributions are made. Committees giving to both state and local candidates should file the original with the Registry and a copy
with the county election commission in any county the committee is making contributions.
r3;Address 2. Name of Committee
Cow,+ ~.Q r Lvor%&'e.
State Zip Code Phone
and Phone Street or Rural Route City
• . S 7v3 s AAA v; tt- Tr~l 3 8 o a~ (BGs~ 7a o
4. Committee Name as it Appears on Checks 5. Type of Candidate Supported (Check One or Both)
State Candidate Local Candidate
I ~ eu..~, wo Mer
6. Treasurer Name 7. E-mail Address
tTrzasurer rri 6-u m Sit rr• Qrv wi 1953 CO_1120m_
Phone
8. Address and Phone Street or Rural Route City State Zip Code
-0-I,cRs R&#A e &XaIe' Ma IV: tie- --l-Al 3780 (g&-NT 1 A
9. Is your committee controlled by a political party on the national, state of local level or by a caucus of a political party established by the
members of either house of the general assembly?
Yes F_1eR0'6t'C'A^ ❑ No
Name of Party (Democrat or Republican)
10. Is your committee affiliated with any other multi-candidate committee? If yes, please list name and address of committee(s) below.
❑Yes ❑No
11. Committee Officers (Name, Position and Address) (Attach additional page if necessary) V1 `t
x29.0 C r O
` N 37 o
d Es t--r ~;R T 37~
Sher ~~u~ ~Na .5a' I ers PD; mac C- 4~'y J i Ll~ ~j 370
TRsb zu,Yr ~ r,
i ner 64,5q 0, Lan;e~- f. filar '1 -N _;7goi
ro
12. Appointing Authority and Treasurer Signature (Both signatures must be witnessed. Treasurer can not witness signature.)
oool
Signature of Treasurer
Signature of Appointing Authority
Signature of Witness
Signature of Witness
ELECTRONIC FILING
If you are interested in filing your campaign financial disclosure statements with the Registry electronically then you will need an ID
and password. You may go to https://apps.tn.govitncamp to see a demonstration of the electronic filing system. If yo the P
box below and sign, the Registry will send you an ID and password along with instructions on how to get started o~ J
filing system. If you have any questions, please feel free to contact the Registry office at (615) 741-7959.
❑ I would like to receive an ID and Password to file campaign financial disclosure statem ele ~D
Registry of Election Finance sT RDtlPgndirig W
SS-1112 (Rev. 05/16) /CO
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For Multicandidate Committees (PACs)
1. DATE OF REPORT 2. NAME OF COMMITTEE
Apai ( a1 1o i ~ --b loL ant
2.A. SHORT NAME OF COMMITTEE (IF APPLICABLE)
3. ADDRESS AND PHONE
Street or Rural Route City State Zip Code Phone
P. . 9,038, v►1t~ 7'Af 3796 a
4. TYPE OF CANDIDATES SUPPORTED
STATE PUBLIC OFFICE LOCAL PUBLIC OFFICE BOTH
5.A. NAME OF POLITICAL TREASURER 5.13. DATE APPOINTED
SH-e~2► G-~ r i a~ i
❑
6. CATEGORY OR REPORT (Check one
FIRST SECOND THIRD FOURTH - PRE- MIDYEAR YEAR-END
QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL
7.A.BEG NING DATE OF REPORTING PERIOD 7.B.ENDING DATE OF REPORTING PERIOD
QI
8. (Check one)
A. This committee is exempt from detailed disclosures because contributions (including in-kind) received total $1,000 or less AND
expenditures total $1,000 or less for this reporting period. I do solemly swear or affirm that the information contained in this statement
is true and that the committee has complied with all applicable provisions of the Campaign Financial Disclosure Act. (Items 10d., 10e.
and 1Of must also be completed.)
B. This committee 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. I do solemly swear or affirm that the information contained
in this statement is true and that the following page(s) are a complete and accurate accounting of all contributions and expenditures
required to be reported by political campaign committees by the Campaign Financial Disclosure Act.
signature of political treasurer date
9. WITNESS SIGNATURE
signature of witness date
10. SUMMARY q
a. BALANCE ON HAND LAST REPORT $ IO D 9. ,JO
/,06-, 00
b. TOTAL RECEIPTS THIS PERIOD $
c. TOTAL DISBURSEMENTS THIS PERIOD $ ✓ 8
o
pit
d. BALANCE ON HAND (10.a. plus 10.b. minus 10.c.) $ 970/. an
e. TOTAL LOANS OUTSTANDING ..........\r . $
f. TOTAL OBLIGATIONS OUTSTANDING &V $
SS-1122(Rev.2106)£ RDA Pending
IV's wa
SUMMARY PAGE - PAC
111. NAME OF COMMITTEE (In Full) ~ ~ q 12. REPORT COVERING THE PERIOD
IJ~~llr1~ C~J611/1 P left-P1 IiC~OIK41?t' FROM ~ &Ile TO:
RECEIPTS
13. 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 13.a. and 13.b.) $ ~v • 00
14. LOANS RECEIVED THIS REPORTING PERIOD $
15. INTEREST RECEIVED THIS REPORTING PERIOD $
16. TOTAL RECEIPTS (add 13.c., 14., and 15.) (must be shown in item 10.b.) $
DISBURSEMENTS
17. EXPENDITURES (other than loan payments)
a. Unitemized Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage,
gasoline) z/6,39
11~1~t~..S-i ~L~.~._71~Aryt~Artft~ $ ~ : DO ~3~s/t8J
$
$
$
$
Total of Expenditures ($100 or less each payee) $
b. Itemized Expenditures (Over $100 each payee this period) $
c. Independent Expenditures
d. TOTAL EXPENDITURES (other than loan repayments)(add 17.a., 17.b. and 17.c.) 8
18. LOAN REPAYMENTS MADE THIS PERIOD $ -19--
19. TOTAL DISBURSEMENTS (add 17.d. and 18.) (must be shown in item 10.c.) a
20.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 20.a. and 20.b.) $
21. LOANS
LOANS OUTSTANDING (must be shown in item 10.e.)
22.013LIGATIONS
a. Unitemized Obligations Outstanding ($100 or less each) $
b. Itemized Obligations Outstanding (Over $100 each) $
c. TOTAL OBLIGATIONS OUTSTANDING (add 22.a. and 22.b.) (must be shown i item 10.f.) $
SS-1136 (Rev. 11 /04) Page a of
ITEMIZED STATEMENT OF EXPENDITURES - PAC
1. NAME OF COMMITTE 2. REPORT COVERING THE PERIOD
FROM: ~ V~l 0:
ount
3. TOTAL ITEMIZED EXPENDITURES FROM PRECEDING PAGE (enter $0 if first itemized page) a1.O(7
4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED EXPENDITURE (expenditures totaling more than $100 to any payee during the period). If the ex-
penditure is an in-kind contribution to a candidate, please remember to include the purpose of the expenditure (e.g. postage, printing) along with the candidate's name in
the ur ose of expenditure section.
First Name Middle Name urpose of Expenditure aunt of Expenditure
Last Name/Business Name
7N red t?-P DUASS C2,A . 00
Address Date of Expenditure
6 to to `9 0~2 D ~ 64/
City State Zip Code
/l i n s Dot Tip 3 746 0
First Name Middle Name Purpose of Expenditure mount of Expenditure
Last Name/Business Name
Address ate of Expenditure
City State Zip Code
First Name Middle Name Purpose of Expenditure mount of Expenditure
Last Name/Business Name
Address Date of Expenditure
City State Zip Code
First Name Middle Name Purpose of Expenditure mount of Expenditure
Last Name/Business Name
Address
ate of Expenditure
City State Zip Code
First Name Middle Name Purpose of Expenditure %mount of Expenditure
Last Name/Business Name
Address Date of Expenditure
City State Zip Code
First Name Middle Name urpose of Expenditure mount of Expenditure
Last Name/Business Name
Address ate of Expenditure
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 campaign expenditures, this amount must be shown in item 17b. of summary.) SS-1119-E (Rev. 1/00) Page of RDA 1159
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For Multicandidate Committees (PACs)
1. DATE OF REPORT 2. NAME OF COMMITTEE
2.A. SHORT NAME OF COMMITTEE (IF APPLICABLE)
3. ADDRESS AND PHONE
Street or ral Route City State Zip Code Phone
12,01 703 6~ Iat, v i t jr- TW 3780x,
4. TYPE OF CANDIDATES SUPPORTED
STATE PUBLIC OFFICE E] LOCAL PUBLIC OFFICE BOTH
5.A. NAME OF POLITICAL TREASURER 5.B. DATE APPOINTED
5he-2ml CRV_0I 1112-7 /1'7
6. CAT RY OR REPORT (Check one) ❑ ❑ ED 0 El
T SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END
QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL
7.A.BEGINNING DATE OF REPORTING PERIOD 7.B.ENDING DATE OF REPORTING PERIOD
S~Nu~R ► (o AO 19 MAaak i o9v►8
8.(Check one)
A. This committee is exempt from detailed disclosures because contributions (including in-kind) received total $1,000 or less AND
expenditures total $1,000 or less for this reporting period. I do solemly swear or affirm that the information contained in this statement
is true and that the committee has complied with all applicable provisions of the Campaign Financial Disclosure Act. (Items 10d., 10e.
and 1 Of must also be completed.)
B. This committee 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. I do solemly swear or affirm that the information contained
in this statement is true and that the following page(s) are a complete and accurate accounting of all contributions and expenditures
required to be reported by political campaign committees by the Campaign Financial Disclosure Act.
/g e, 14A o U~
signature of political treasurer da
9. WITNESS SIGNATURE
S. ctu~ 7 /s
signature of witness date
10. SUMMARY
a. BALANCE ON HAND LAST REPORT . $ 9 D .!5r.3
b. TOTAL RECEIPTSTHIS PERIOD
331. ov
c. TOTAL DISBURSEMENTS THIS PERIOD $
d. BALANCE ON HAND (10.a. plus 10.b. minus 10.c.) $
e. TOTAL LOANS OUTSTANDING 1s .................a...... $
V,
f. TOTAL OBLIGATIONS OUTSTANDING 4 .C~/~ j $
N
e40 NTC cl)
SS-1122(Rev. 2/06) ~d CTOIJ, RDA Pending
~yZL ll OL6~ L
._..,._.-Y...,,,~..~
SUMMARY PAGE - PAC
11. ~NAME OF COMMITTEE (In Full) 12. REPORT COVERING THE PERIOD
1✓ I D~•Cri~ (~pLl~vL v\ t~QI~ FROM TO.~ 31
RECEIPTS
13. CONTRIBUTIONS (other than loans and interest)
a. Unitemized Contributions ($100 or less from each source this period) $ IJ~.
b. Itemized Contributions (over $100 from each source this period) $ 77 jj
c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 13.a. and 13.b.) $ 14. LOANS RECEIVED THIS REPORTING PERIOD $ -e-
15. INTEREST RECEIVED THIS REPORTING PERIOD $
16. TOTAL RECEIPTS (add 13.c., 14., and 15.) (must be shown in item 10.b.) 3/S.
DISBURSEMENTS
17. EXPENDITURES (other than loan payments)
a. Unitemized Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage,
gasoline)
RAil
$
$
$
$
$
Total of Expenditures ($100 or less each payee) 00
b. Itemized Expenditures (Over $100 each payee this period) $ a
c. Independent Expenditures $
d. TOTAL EXPENDITURES (other than loan repayments)(add 17.a., 17.b. and 17.c.) $ 3.3~.
18. LOAN REPAYMENTS MADE THIS PERIOD $
19. TOTAL. DISBURSEMENTS (add 17.d. and 18.) (must be shown in item 10.c.) 3 C2
20.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 20.a. and 20.b.) $
21. LOANS
LOANS OUTSTANDING (must be shown in item 10.e.)
22. OBLIGATIONS
a. Unitemized Obligations Outstanding ($100 or less each) $
b. Itemized Obligations Outstanding (Over $100 each) $
c. TOTAL OBLIGATIONS OUTSTANDING (add 22.a. and 22.b.) (must be shown i item 10.f.) $
SS-1136 (Rev. 11/04) Page CA of
4
ITEMIZED STATEMENT OF EXPENDITURES - PAC
1. NAME OF COMMITTEE 2. REPORT COVERING THE PERIOD
U Cn FROM: 1//Q lg TO: 41.31 1
Amount
3. TOTAL ITEMIZED 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). If the ex-
penditure is an in-kind contribution to a candidate, please remember to include the purpose of the expenditure (e.g. postage, printing) along with the candidate's name in
the purpose of expenditure section.
First Name Middle Name urpose of Expenditure mount of Expenditure
Last NameBusJame
J s a
Fi
Add Date of Expenditure
`r'e's~s -Q
City ,tate Zip Code
First N 4middlaNam ame ePurpose of Expenditure mount of Expenditure
Last Name/Business Name
Address ale of Expenditure
City State Zip Code
First Name Middle Name Purpose of Expenditure mount of Expenditure
Last Name/Business Name
Address ate of Expenditure
city State Zip Code
First Name Middle Name Purpose of Expenditure mount of Expenditure
Last Name/Business Name
Address ate of Expenditure
city State Zip Code
First Name Middle Name Purpose of Expenditure mount of Expenditure
Last Name/Business Name
Address Date of Expenditure
City State Zip Code
First Name Middle Name urpose of Expenditure mount of Expenditure
Last Name/Business Name
ate of Expenditure
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 campaign expenditures, this amount must be shown in item 171b. of summary.) SS-1119-E (Rev. 1/00) Page of RDA 1159
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For Multicandidate Committees (PACs)
1. DATE OFREPORT 2. NAME OF COMMITTEE
61,o I 1-31 V
2.A. SHORT NAME OF COMMITTEE (IF APPLICABLE)
3. ADDRESS AND PHONE
Street or Rural Route City State Zip Code Phone
4. TYPE OF CANDI ATES SUPPORTED
STATE PUBLIC OFFICE LOCAL PUBLIC OFFICE BOTH X
5.A. NAME OF POLITICAL TREASURER 5.13. DATE APPOINTED
J hG/122~ ~l7 r7
6. CATEGORY OR REPORT (Check one) ❑ ❑ a 0
FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END
QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL
7.A.BEGINNING DATE OF REPORTING PERIOD 7.B.ENDING DATE OF REPORTING PERIOD
'711 I IZ151 IE
8. (Check one)
A. ❑ This committee is exempt from detailed disclosures because contributions (including in-kind) received total $1,000 or less AND
expenditures total $1,000 or less for this reporting period. I do solemly swear or affirm that the information contained in this statement
is true and that the committee has complied with all applicable provisions of the Campaign Financial Disclosure Act. (Items 10d., 10e.
and 10f must also be completed.)
B. N1,000 his committee is required to file a detailed financial disclosure because contributions (including in-kind) received total more than
and/or expenditures total more than $1,000 for this reporting period. I do solemly swear or affirm that the information contained
in this statement is true and that the following page(s) are a complete and accurate accounting of all contributions and expenditures
required to be reported by political campaign committees by the Campaign Financial Disclosure Act.
signature of political treasurer date
9. WITNESS SIGNATURE
signature of witness Ate
10. SUMMARY
a. BALANCE ON HAND LAST REPORT ................................................c............................
00
$
b. TOTAL RECEIPTSTHIS PERIOD W~.F_IvFD
c. TOTAL DISBURSEMENTS THIS PERIOD .3.0.018........................ $ SU
CoUtqr(
d. BALANCE ON HAND (10.a. plus 10.b. minus 10.c. LOU ON' ® +W~ f
) ...................FILE ~ $
e. TOTAL LOANS OUTSTANDING $
f. TOTAL OBLIGATIONS OUTSTANDING $
SS-1122(Rev. 2/06) RDA Pending
SUMMARY PAGE - PAC
11. NAME OF COMMITTEE (In Full) 12. REPORT COVERING THE PERIOD
V (Olt! v1 ntinun4vi (,0o FROM / TO:
RECEIPTS
13. CONTRIBUTIONS (other than loans and interest)
a. Unitemized Contributions ($100 or less from each source this period) CEO
b. Itemized Contributions (over $100 from each source this period) $
c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 13.a. and 13.b.) $
14. LOANS RECEIVED THIS REPORTING PERIOD
15. INTEREST RECEIVED THIS REPORTING PERIOD
16. TOTAL RECEIPTS (add 13.c., 14., and 15.) (must be shown in item 10.b.) $
DISBURSEMENTS
17. EXPENDITURES (other than loan payments)
a. Unitemized Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage,
gasoline)
T/V F~ $
Dona +7 2n $ 50.0,0
I V
Total of Expenditures ($100 or less each payee) $ ~~L>
b. Itemized Expenditures (Over $100 each payee this period) G
$,A Joe,
c. Independent Expenditures $
d. TOTAL EXPENDITURES (other than loan repayments)(add 17.a., 17.b. and 17.c.)~-
18. LOAN REPAYMENTS MADE THIS PERIOD $
19. TOTAL DISBURSEMENTS (add 17.d. and 18.) (must be shown in item 10.c.)
20. 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 20.a. and 20.b.) $
21. LOANS
LOANS OUTSTANDING (must be shown in item 10.e.)........ $
22. OBLIGATIONS
a. Unitemized Obligations Outstanding ($100 or less each) $
b. Itemized Obligations Outstanding (Over $100 each) $
c. TOTAL OBLIGATIONS OUTSTANDING (add 22.a. and 22.b.) (must be shown i item 10.f.) $
SS-1136 (Rev. 11/04)
Page --A_ of A_
ITEMIZED STATEMENT OF CONTRIBUTIONS - PAC
1. NAME OF COMMITTEE 2. REPORT COVERING THE PERIOD
f O FROM: + T0: / 5'
F- I Amoun
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 during the period)
First Name M.I. Last a/Organization Name AmountofContri,"
Address
A LO
City State Zip Code
7- 39ff6Date otContribution
Occupation / < br /V Employer
First Name M.I. Last Name/Organization Name AmountofContrikilion
Address
city Stale Zip Code
Date oiContribution
Occupation Employer
First Name M.I. Last Name/OrganizationName AmountofConhibiAon
Address
City State Zip Code
Date of Contribution
Occupation Employer
First Name M.I. Last Name/Organization Name Amounto(Cmirilbution
Address
City State Zip Code Date oiContribution
Occupation Employer
First Name M.I. Last Name/Organization Name AmountofContribution
Address
City State Zip Code
Date of Contribution
Occupation Employer
First Name M.I. Last Name/Organization Name Airounto(ConMution
Address
City State Zip Code
Date of Contribution
Occupation Employer
5.TOTAL ITEMIZED CONTRIBUTIONS
(Carry forward to item 3. of next page if additional pages of this form are used.) 05-
(If this is the last page of contributions, this amount must be shown in item 13b. of summary.) / :
SS-1119-C (Rev. 2/06) Page of -4- RDA 1159
I~
ITEMIZED STATEMENT OF EXPENDITURES - PAC
1. NAM OF COMMITTEE 2. REPORT COVERING THE PERIOD
FROM: ` / .y T0:
Amou t
3. TOTAL ITEMIZED 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). If the ex-
penditure is an in-kind contribution to a candidate, please remember to include the purpose of the expenditure (e.g. postage, printing) along with the candidate's name in
the purpose of ex enditure section.
First Name Middle Name urpose of Expenditure Amount of Expenditure
LastNa usin Name
Address
Date of Expenditure
3742 /R C •
city A/ Ctl7 T Stato (4&p Code
3 J 70 1
First Name Middle Name Purpose of Expenditure ount of Expenditure
Last Name/Business Name
•_r
Sri It ri~vi . ?j()
Address ! ate of Expenditure to/ 5.
city State Zip 1`7t)l A; .911-1
First Name Middle Name Purpose of Expenditure ount of Expenditure
Last Name/Business Nam
Address
U ate of Expenditure
cp S C
At.
City State Zip Code
Aiw~jvglle_ 7-W cis
First Name Middle Name Purpose of Expenditure ount of Expenditure
Last Na eBusiness Nam < - a
14 (Ke
Add`~j
J ate of Expenditure
r9~ CJ ~ I C~ 11
City ' Ile, State Zip Code PoE A; r 7
First Name 'Qj Middle Name Purpose of Expenditure mount of Expenditure
Last NameBusiness Name
Address Date of Expenditure
City State Zip Code
First Name Middle Name urpose of Expenditure ount of Expenditure
Last Name/Business Name
Address ate of Expenditure
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 campaign expenditures, this amount must be shown in item 17b. of summary.) SS-1119-E (Rev. 1/00) Page of RDA 1159
CAMPAIGN FINANCIAL DISCLOSURE STATEMENT
For Multicandidate Committees (PACs)
1. DATE ~OFREPORT 2. NAME OF COMMITTEE
2.A. SHORT NAME OF COMMITTEE (IF APPLICABLE)
3. ADDRESS AND PHONE
Street or Rural Route City State Zip Code Phone
4. TYPE OF CANDIDATES SUPPORTED
STATE PUBLIC OFFICE LOCAL PUBLIC OFFICE BOTH
5.A. NAME OF POL`I\TICAL TREASURER 5.13. DATE iAPPOiINTED
9RT eclc one) ❑ Q
6. CATQ ORY OR REP
FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAR-END
QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENT
7.A.BEGINNING DATE OF REPORTING PERIOD 7.B.E LADING DATE OF REPORTING PERIOD
8. (Check one)
A. This committee is exempt from detailed dtsdosures because contributions (including in4dnd) received total $1,000 or less AND
expenditures total $1,000 or less for this reporting period. I do solemly swear or affirm that the information contained in this statement
is true and that the committee has complied with all applicable provisions of the Campaign Financial Disclosure Act. (Items 10d., 10e.
and 1Of must also be completed.)
B. r-1 This committee 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. 1 do solemly swear or affirm that the information contained
in this statement is true and that the following page(s) are a complete and accurate accounting of all contributions and expenditures
required to be reported by political campaign committees by the Campaign Financial Disclosure Act.
7_
signature cal treasurer date
9. WITNESS SIGNATURE
7-10 - /,L
Lh4nalliure of witness date
10. SUMMARY
3 {
a. BALANCE ON HAND LAST REPORT $ - / S
b. TOTALRECEIPTSTHIS PERIOD $
` ( r J~
c. TOTAL DISBURSEMENTSTHISPERIOD $
d. BALANCE ON HAND (10.a. plus 10.b. minus 10.c.) $ r S t, : L-((
e. TOTAL LOANS OUTSTANDING A............................................. $
f. TOTAL OBLIGATIONS OUTSTANDING $
,..t.
SS-1122(Rev 2/06) RDA Pending
Report - TN.gov Page 1 of 4
Online Campaign Finance
Annual Mid Year Supplemental (2015) for BLOUNT COUNTY REPUBLICAN WOMEN
BEGINNING BALANCE
$7,191.94
RECEIPTS
MONETARY CONTRIBUTIONS, UNITEMIZED
$5,026.00
MONETARY CONTRIBUTIONS, ITEMIZED
No itemized monetary contributions found on this report.
TOTAL CONTRIBUTIONS (OTHER THAN ADJUSTMENTS, LOANS, AND INTEREST)
$5,026.00
CONTRIBUTION ADJUSTMENTS
No contribution adjustments found on this report.
LOANS RECEIVED
No loans found on this report.
INTEREST RECEIVED
$0.00
TOTAL RECEIPTS
$5,026.00
DISBURSEMENTS
EXPENDITURES, UNITEMIZED
No unitemized expenditures found on this report.
EXPENDITURES, ITEMIZED
16 items found, displaying all items.
Vendor C/P Purpose Kn Independent S/O Date Amount
BB&T
216 FOOTHILLS MALL DR DEPOSIT SLIPS R O 04/02/2015 $9.43
MARYVILLE, TN 37801 , -0 ;
CHECKS d le 02/18/2015 $29.73
BB&T
r
216 FOOTHILLS MALL DR
MARYVILLE, TN 37801
https:Happs.tn.gov/tncamp-app/user/report_full.htm 7/5/2015
Report - TN.gov Page 2 of 4
Vendor C/P Purpose In Independent S/O Date Amount
Kind
BLOUNT COUNTY PUBLIC
LIBRARY
FOOD FEE 04/13/2015 $10.00
508 N. CUSICK STREET
MARYVILLE, TN 37803
BLOUNT COUNTY PUBLIC
LIBRARY
FOOD FEE 02/23/2015 $10.00
508 N. CUSICK STREET
MARYVILLE, TN 37803
BLOUNT COUNTY REPUBLICAN
CAMPAIGN 2007
P COMPLIMENTARY TICKETS 04/2912015 $50.00
4123 CONGER RD
LOUISVILLE, TN 37777
MILLS, SUSAN
REIMBURSEMENT FOR 05/18/2015 $194.69
311 DANIELLE COURT DECORATIONS
MARYVILLE, TN 37803
MONTGOMERY COUNTY
REPUBLICAN WOMEN LADIES DAY ON THE HILL
ATTENDANCE 02/26/2015 $216.00
4801 ALBRIGHT RD
CLARKSVILE, TN 37043
MONTGOMERY COUNTY
REPUBLICAN WOMEN
CONTRIBUTION 02/21/2015 $100.00
4801 ALBRIGHT RD
CLARKSVILE, TN 37043
R. J. COURTYARD
3749 AIRPORT HWY FOOD 06/27/2015 $500.00
ALCOA, TN 37701
SMOKY MTN SCOTTISH FESTIVAL
& GAMES
TENT SPACE/ PUBLICITY 03/30/2015 $35.00
124 DEBUSK LANE
KNOXVILLE, TN 37922
STAPLES
1090 HUNTERS CROSSING BREAKFAST TICKET PRINTING 05/18/2015 $43.89
ALCOA, TN 37701
DUES 06/13/2015 $280.00
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Vendor C/P Purpose In Independent S/O Date Amount
Kind
TENNESSEE FEDERATION OF
REPUBLICAN WOMEN
2669 SUFFOLK DRIVE
KINGSPORT, TN 37660
TENNESSEE FEDERATION OF
REPUBLICAN WOMEN
DUES 03/12/2015 $364.00
2669 SUFFOLK DRIVE
KINGSPORT, TN 37660
TENNESSEE FEDERATION OF
REPUBLICAN WOMEN
DUES 01/25/2015 $253.00
2669 SUFFOLK DRIVE
KINGSPORT, TN 37660
UNITED STATES POSTAL
SERVICE
POST OFFICE BOX 01/16/15 $56.00
226 KELLER LANE
MARYVILLE, TN 37803
UNITED VETERANS OF BLOUNT
COUNTY MONUMENT BRICK -
DURWOOD SWANSON 04/27/2015 $150.00
305 COURT STREET
MARYVILLE, TN 37804
TOTAL EXPENDITURES (OTHER THAN ADJUSTMENTS, LOAN PAYMENTS AND OBLIGATION PAYMENTS)
$2,301.74
EXPENDITURES ADJUSTMENTS
No expenditure adjustments found on this report.
LOAN PAYMENTS
No loan payments found on this report.
OBLIGATION PAYMENTS
No obligation payments found on this report.
TOTAL DISBURSEMENTS
$2,301.74
ENDING BALANCE
$9,916.20
In-Kind Contributions & Obligations are not included in the report ending balance.
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IN-KIND CONTRIBUTIONS
IN-KIND CONTRIBUTIONS, UNITEMIZED
$0.00
IN-KIND CONTRIBUTIONS, ITEMIZED
No itemized in-kind contributions found on this report.
TOTAL IN-KIND CONTRIBUTIONS
$0.00
OBLIGATIONS
OBLIGATIONS, UNITEMIZED
$0.00
OBLIGATIONS, ITEMIZED
No obligations found on this report.
OBLIGATIONS, OUTSTANDING
No outstanding obligations found on this report.
TOTAL OBLIGATIONS OUTSTANDING
$0.00
https://apps.tn.gov/tncamp-app/user/report_full.htm 7/5/2015
l1[uLU1* Keport- IN.gOV
4th Quarter for REPUBLICAN WOMEN'S CLUB OF BLOUNT CO submitted on
01/21/2015
BEGINNING BALANCE
$7,931.94
RECEIPTS
MONETARY CONTRIBUTIONS, UNITEMIZED
$100.00
MONETARY CONTRIBUTIONS, ITEMIZED
No itemized monetary contributions found on this report.
TOTAL CONTRIBUTIONS (OTHER THAN ADJUSTMENTS, LOANS, AND INTEREST)
$100.00
CONTRIBUTION ADJUSTMENTS
No contribution adjustments found on this report.
LOANS RECEIVED
No loans found on this report.
INTEREST RECEIVED
$0.00
TOTAL RECEIPTS
$100.00
>
DISBURSEMENTS =
t
EXPENDITURES, UNITEMIZED `
One item found. 1
Purpose
_ Amount
MEMORIAL GIFT $100.00
One item found. 1
EXPENDITURES, ITEMIZED
2 items found, displaying all items. 1
Vendor C/P Purpose In-Kind Independent S/O Date Amount
BLOUNT COUNTY PUBLIC LIBRARY
508 N. CUSICK STREET MEETING ROOM RENTAL 11/20/2014 $390.00
MARYVILLE, TN 37803
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1IZZ/Zu1b Neport- IN.goV
CRISP ACCOUNTING AND TAX SERVICE
1825 WEST BROADWAY AVE PROFESSIONAL SERVICES 01/12/2015 $350.00
MARYVILLE, TN 37801
2 items found, displaying all items. 1
TOTAL EXPENDITURES (OTHER THAN ADJUSTMENTS, LOAN PAYMENTS AND OBLIGATION PAYMENTS)
$840.00
EXPENDITURES ADJUSTMENTS
No expenditure adjustments found on this report.
LOAN PAYMENTS
No loan payments found on this report.
OBLIGATION PAYMENTS
No obligation payments found on this report.
TOTAL DISBURSEMENTS
$840.00
ENDING BALANCE
$7,191.94
In-Kind Contributions & Obligations are not included in the report ending balance.
OUTSTANDING LOANS
$0.00
No outstanding loans found on this report.
IN-KIND CONTRIBUTIONS
IN-KIND CONTRIBUTIONS, UNITEMIZED
$0.00
IN-KIND CONTRIBUTIONS, ITEMIZED
No itemized in-kind contributions found on this report.
TOTAL IN-KIND CONTRIBUTIONS
$0.00
OBLIGATIONS
OBLIGATIONS, UNITEMIZED
https://apps.tn.gov/tncam p-app/search/pub/report_ful I.htm?reportld=58826 213
'uuJzul5 Keport- i N.gov
$0.00
OBLIGATIONS, ITEMIZED
No obligations found on this report.
OBLIGATIONS, OUTSTANDING
No outstanding obligations found on this report.
TOTAL OBLIGATIONS OUTSTANDING
$0.00
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APPOINTMENT OF POLITICAL TREASURER
For Multi-Candidate Committees (PACs)
INSTRUCTIONS
This form must be used to appoint a political treasurer as required by the Campaign Financial Disclosure Act (T.C.A. §2-10-105)
for multi-candidate committees (PACs). No funds may be received or expended for a future election until a political treasurer has
been appointed. A new form must be filed if the treasurer is changed.
Committees that make contributions only to candidates for state public office must file this form and a $100 annual fee with the
Registry of Election Finance, 404 James Robertson Parkway, Suite 104, Nashville, TN 37243-1360. Committees that make
contributions only to candidates for local public office must file with the local county election commission in the county where the
contributions are made. Committees giving to both state and local candidates should file the original with the Registry and a copy
with the county election commission in any county the committee is making contributions.
1. Date 2. Name of Committee
3. Address and Phone Street or Rural Route City State Zip Code Phone
A 0. BIQ~ 03S D~ Y, D Z 8 3oc- 81
4. Committee Name as it Appears on Checks 5. Type of Candidate Supported (Check One or Both)
I D L [State Candidate ocal Candidate
6. Treasurer Name
Susan Me/ S
7. Treasurer Address and Phone Street or Rural Route city state Zip Code Phone
8. Is your committee controlled by a political party on the national, state of local level or by a caucus of a political party established by the
tubers of eith house of the general assembly?
Yes n/Lhlt e4_P1 No
Name of Party (Democrat or Republican)
9. Is your committee affiliated with any other multi-candidate committee? If yes, please list name and address of committee(s) below.
❑ Yes ❑ No
10. Committee Officers (Name, Position and Address) (Attach additional page if necessary)
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11. p 'nting Authority an reasu Signat re (Both signatures must be witnessed. Treasurer can t witness signature.)
Signature Appointing Authority Signature of Tre urer
4~1
Signature of With s Signature of Witness
ELECTRONIC FILING
If you are interested in filing your campaign financial disclosure statements with the Registry electronically then you will need an ID
and password. You may go to www.tennesseeanytime.org/tncamp/ to see a demonstration of the electronic filing system. If you
check the box below and sign, the Registry will send you an ID and password along with instructions on how to get started on the
electronic filing system. If you have any questions, please feel free to contact the Registry office at (615) 741-7959.
❑ I would like to receive and ID and Password to file campaign financial disclosure statements electronically.
Registry of Election Finance
SS-1112 (Rev. 8/08) RDA Pending
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