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Grothjahn, Harry CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 2.a. NAME OF CANDIDATE OR COMMITTEE Al- --,,2- o ~ 2.b. IF COMMITTEE, NAME OF CANDIDATE ELECTION DATE -mil ?-e,) 4.a. CAMPAIGN ADDRESS AND PHONE Street Rural Ste A IState Zip Code Phone 0 7`~1 3 70 7a Vim) 13 L 4.b. CANDIDATE'S HOMIL ADDRESS (if different than 4.a.) Street gckl ural Ro City State Zi Code Pho e /3~ `LL 1,iL& l 3 7' c ~6~ 3~0~4 5. OFFICE SOUGHT (include district number, if appli able) 6. NAME OF POLITICAL TREASURER (may be candidate) mftop, pQ k 7. CATEGORY OR RtIPORT (Check one) FIRST SECOND THIRD FOURTH PRE- PRE- MID-YEAR YEAREND QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF REPORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIOD `20 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. Qethis 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 enefit o ea+~did r ny other nonpolitical purpose as defined by the eral internal revenue code. signature of political treasurer date signatu o can ate date 11. WITNESS SIGNATURE JL4~u E I 'y L V (t ignature of witness date signature of witness date 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ b. TOTAL RECEIPTS THIS PERIOD $ c. TOTAL DISBURSEMENTS THIS PERIOD $ M1 234 d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) .....................Q ..I! $ ~ ~ ass e. TOTAL LOANS OUTSTANDING Z~......... El QLIM............ $ T. f f. TOTAL OBLIGATIONS OUTSTANDING R.Z S ZO~.............. . $ ELECTION !9 ~a of SS-1109 (Rev. 2106) Page 1 J RDA 1159 S~EZ~Y, SUMMARY PAGE - CANDIDATE 13. NAME OF CANDIDATE C77, TTE (In Full) 14. REPORT COVERING T E PERIOD ~ FROM* /f T0: ~ll 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) $ 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 PERIOD $ 18. TOTAL RECEIPTS (add 15.c., 16., and 17.) (must be shown in item 12.b.) $ fJ~j DISBURSEMENTS 19. EXPENDITURES (other than loan payments) a. Expenditures ($100 or less each payee this period) (must be listed by category - e.g., printing, postage, gasoline) Total of Expenditures ($100 or less each payee) $ b. Itemized Expenditures (Over $100 each payee this period) $ c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ . 20. LOAN REPAYMENTS MADE THIS PERIOD $ l 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) $ 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. 4/02) ~ Page - of ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OMMITTEE 2. REPORT COVERING THE PERIOD FROM?5! I , TO:41 y~ Amo nt 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 m Middle Name Contribution Received For: Amount of Contribution Last Name/Orga ation ame 25nmary Election ❑ General Election / Address ❑ Runoff (Local Elections Only) , City State Code Date of Contribution Aggregate This Election Occupation / ~ ~ J Employer 6 First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name iddle Name Contribution Received For: Amount of Contribution as Name /Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer FlrstName Middle Name onto ubon eceive or: 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 1 (Carry forward to item 3. of nerd page if additional pages of this form are used.)~i V (If this is the last page of contributions, this amount must be shown in item 15b. of summary.) SS-1131(Rev.. 2106) Page of~ RDA 1159 1 ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME OF CANDIDATE R/COMMITTEE 2. REPORT COVERING THE PERIOD FROM 14/-/ . T0: _:2 Amount 3. TOTAL ITEMIZED CAMPAIGN EXPE DITURES FROM PRECEDING PAGE (enter $0 if first itemized page) 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED EXPENDITURE (expenditures totaling more than $100 to any payee during the period) First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name U/ Address Ciry ; L Sate- , Zi Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code 5. TOTAL ITEMIZED EXPENDITURES (Carry forward to item 3. of next page if additional pages of this form are used.)~L-~ r (If this is the last page of expenditures, this amount must be shown in item 19b. of summary.) SS-1129 (Rev. 4/02) Page ot-5 RDA 1159 ITEMIZED STATEMENT OF LOANS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD / FROM- TO:_/ 3. COMPLETE THE APPROPRI E ITEMS FOR EAC EMIZED LOAN (loans totaling more than $100 from any source during the period) Complete the Following for the Source of the Loan First Name Middle Name Outstanding Loan Balance Loans Loan Outstanding Loan Balance (Beginning of Period) Received P ents (End of Period) ~O 171 ' t~ ?me /rp~an' tion Name { !J / l AddrQae~ _ Loan Received For: Date of Loan /L_J Vlmmary Election ❑ General Election 3J,CJ/J/emul {~J City I Stat Zi Code J w( vZ~ 7 d ❑ Runoff (Local Elections Only) List All Endorsers or Guarantors for Above Loan (If more space is needed please attach a page) First me) Middle Name First Name Middle Name Last Namll rganizati me Last Name/Organization Name ~rZA Q Addre s-31-/ 1! / i / Address City / I~\/ V- F-L~ e R code a city State Zip Code Amount Guarante Outstanding 9J aOV mount Guaranteed Outstanding First Name [l 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 NamelOrganization 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 4. Totals for all Loans (complete on last page of itemized loans) Outstanding Loan Balance Loans Loan Outstanding Loan Balance (Total loans received should also be shown in item 16. on summary page.) (Beginning of Period Received Payments End of Period (Total loan payments should also be shown in item 20. on summary page.) p~ (Total outstanding loan balance should also be shown in item 12.e. on front page.) 3 03 0- SS-1132 (Rev. 4102) Page of RDA 1159 CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 2.a. A OF CANDIDATE OR COMMITTEE 2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE a;' 4.a. CAMPAIGN ADDRESS AND PHONE Street or Rural oute City State Zip Code Phone 0 Ey i"~o a T-1,J 3 770 t q6Y-rS`-1 y 4.b. CANDIDATE'S HOME ADDRESS (if different than 4.a.) Street or Rural Route Ci State Code P one - 5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) 7. CATEGO Y 014 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 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 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 c r for?ny other nonpolitical purpose as defined by the f al internal revenue code. 41- ao(9 q-10 -o signal re of can 'ate date signature of political treasurer date 11. WITNESS SIGNATURE ` (Agn IF signature of witness date signature of witness date 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ 7 b. TOTAL RECEIPTS THIS PERIOD $ !~®v c. TOTAL DISBURSEMENTS THIS PERIOD $ d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) $ n, e. TOTAL LOANS OUTSTANDING r ' $ 3 C f. TOTAL OBLIGATIONS OUTSTANDING $ APR 10 20-- cn .,'_~Uf i COLINFe L9 SS-1109 (Rev. 2/06) ELECTIO[~ Page 1 of RDA 1159 t wd z ~ V o SUMMARY PAGE - CANDIDATE 13. NAME OF CANDIDATE OR COMMITTEE (In Full) 14. REPORT COVERING THE PERIOD FROM: TO: RECEIPTS 15. CONTRIBUTIONS (other than loans and interest) a. Unitemized Contributions ($100 or less from each source this period) $s b. Itemized Contributions (over $100 from each source this period) c. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ 16. LOANS RECEIVED THIS REPORTING PERIOD $ ,rG" 17. INTEREST RECEIVED THIS REPORTING PERIOD C 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) PA-AV $ -J~ $ 371 02 ~.S $ $ $ $ $ b Total of Expenditures ($100 or less each payee) $ b. Itemized Expenditures (Over $100 each payee this period) $ 4),4175- 09 / c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ i© ,6A 20. LOAN REPAYMENTS MADE THIS PERIOD $ 63p- 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ Z b (e 5~Y 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) $ 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) $ (7 c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 12.f.) $ ?S .0 SS-1133 (Rev. 4102) Page _z,__ of 7 ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME 0 NDIDATE OR COMMI E ,J 2. REPORT COVERING THE PERIOD 74- FROM: TO: j 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 any contributor) First Namg~ / Middle Name Contribution Received For: Amount of Contribution cl b ~ Last NamelOrg nizati n Na a ~rimary Election ❑ General Election Address / . ) ,j ~ ❑ Runoff (Local Elections Only) city l v~~ / 7 S7kj Zip Code 70 Date of Contribution Aggregate This Election Occupation Em 6? Les, /Z First Na a Middle Name Contribution Received For: Amount of Contribution Last Namel anizati, nplyn rimary Election ❑ General Election p~ 14 Address 1,0(/ , 3 O ❑Runoff (Local Elections Only) city State Zip Code Date of Contribution Aggregate This Election 7r Occupation l~l2e Employe / First Name iddle Name Contribution Received For: Amount of Contribution Last Name /Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name Middle Name Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) City State Zip Code Date of Contribution Aggregate This Election Occupation Employer 5. TOTAL ITEMIZED CONTRIBUTIONS (Carry forward to item 3. of next page if additional pages of this form are used.) (If this is the last page of contributions, this amount must be shown in item 15b. of summary.) 750e Env. SS-1131(Rev. 2/06) Page 3 of RDA 1159 r , ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME 0 CANDIDATE OR COMMI EE 2. REPORT COVERING THE PERIOD f FROM: T0: Amount 3. TOTAL ITEMIZED CA PAIGN 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 Las melBusin s Name Address City Stale Zip Code 3-77c( First Name Middle Name Purpose of Expenditure Amount of Expenditure as rr lp usiness Name Address City State Zip Code First Name Middle Name Purpose of Expenditure I Amount-of Expenditure 3~~IZ P406~ 6 40S e Las a usiness N me Address 6le City State Zip Code 77,/13-7701 First Name Middle Name Pu oSe of Expenditure Amount of Expenditure La t Na a/Business Name 7C~~~la?" 3 0 f c Address ~l •M t`7~,r 3107 l# mJ . City State Zip Code 3 7 ~ First Name Middle Name Purpo a of Expenditure Amount of Expenditure as / usiness N e ~tSA) c?P Addr s City State Zip Code 7,01 First Name Middle Name Purpose Expenditure AmAt,nt of Expenditure Las ame/Business Name Address City Code Zip 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.) 4) SS-1129 (Rev. 4/02) Page of RDA 1159 ti ITEMIZED STATEMENT OF LOANS - CANDIDATE 1. NAME OF CAN IDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: T0: 69k, :z0~ 3~3J-i 3. COMPLETE THE APPROORIATE ITEMS FOR EACH ITEMIZED LOAN (loans totaling more than $100 from any source during the period) Complete the Following for the Source of the Loan First Name Middle Name Outstanding Loan Balance Loans Loan Outstanding Loan Balance (Beginning of Period) Received Payments (End of Period) Last Name/Organization Name -7 Address Loan Received For: Date of Loan Primary Election ❑ General Election G City State Zip Codei` V LU ~l ❑ Runoff (Local Elections Only) ` List All Endorsers or Guarantors for Above Loan (If more space is needed please attach a page) First Na a Middle Name First Name Middle Name f~P,1 Last Name/Organization Nam Last Name/Organization Name L2 ) Address , Address 3_ CityO'l State Zip Code City State Zip Code Amount Guaranteed Ou anding 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 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 4. Totals for all Loans (complete on last page of itemized loans) Outstanding Loan Balance Loans Loan Outstanding Loan Balance (Total loans received should also be shown in item 16. on summary page.) Beginnin of Period) Received Payments (End of Period (Total loan payments should also be shown in item 20. on summary page.) (Total outstanding loan balance should also be shown in item 12.e. on front page.) 05 SS-1132 (Rev. 4/02) Page of 777- RDA 1159 r r , ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME OF CANDIDATE OR CO M EE t 2. REPORT COVERING THE PERIOD FROM: ~ TO:~ - noun 3. TOTAL ITEMIZED CAMPAIGN EXPENDITURES FROM PRECEDING PAGE (enter $0 9first itemized page) 3C;- j,;( 4. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED EXPENDITURE (expenditures blding more Ow $100 b any payee during the period) First Name Diddle Name Purpose of Expenditure Amount of Expenditure Last Namelf3usiness Name /6 - nti) L v lJ(~4y '-//77 2 7;7 )U A4-j A-4 l iC f~ Address Gh State Zip Code Fast Name Middle Name Purpose of Expenditure Amount of Expenditure - Last N usiness Name iJL PU7 ! l Address S U7,) 5 Gds 3 First Name Middle Name Purpose of Expenditure Amount of Expenditure LaslNarrfe/8 Address r z s.v Y city State jp Code 77U 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 NameBusaress Name Address City State Zp Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last NameBusiness New Address City State Zp Code 5. TOTAL ITEMIZED EXPENDITURES (Carry forward b darn 3. of next page it additional pages of this form are used.) 2T G IN this Is ftie last page of expends ures, this amount must be shown In dam 19b. of swrwnary.) SS-1129 (Rev. 4/02) Page of 7 RDA 1159 r f ; ITEMIZED STATEMENT OF OBLIGATIONS - CANDIDATE 1. NAME OF CAN ID TE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: - l TO: „ 3. COMPLET HE APP OPRIATE EMS FOR EAC EMIZ 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/Bu 'n s -3 / 7 L Address 3 City 144e-azt-, 7 1) S Zip Code _Q D ' tion f bligation First Name Middle NM e Last NamelBu~ineSS N@ ~ f 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 NamelBusiness 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 / r in item 23b. on summary page.) 4) SS-1127 (Rev. 4/02) Page-77-of 7 RDA 1159 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- Q~ =Candidate irst an1d Last Name: 3. Candidate e-mail address: ~,j 7- V AA- it Rd 4. Campaign ddress and Phone: City State Zip Code Phone F?d, Q~ !30 TN 37701 86S-~'6~-32a 8 5. Home Address and Phone (if different than item 4 above): City State Zip Code Phone l 3 A/ /Q©ek/V-/11 ~sQ 1V4AyvjZ& 7,v 3784 41 6.Office Sought (include district number, if applicable) 7. Part Affiliation 8. Election Year At . ~AYv2 Gak _ 9. Treasurer Name: 10. Treasurer e-mail address: Ole r r►' 11. Treasurer Address and Phone: City State Zip Code Phone Aarc 5/ iee~ ~l q TN 37701 8GS' Yly-aSZ2 12. Candidate and Treasurer Signature (both s' mu essed. easurer can not witness candidate's signature): 4 y RROEMM u t . EB222018 a~ Signature of ndidate J ~ BI~I>hITCOUNiYSignature of Treasurer Signature of Witness Signature of Witness Registry of Election Finance SS-1120 (rev 12/2013)