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Crowe, Dodd Appointment of Political Treasurer For State and Local Candidates and Single-Candidate Committees INSTRUCTIONS The Appointment of Political Treasurer statement must be used to appoint a political treasurer as required by the Campaign Financial Disclosure Act (T.C.A. § 2-10-105) for state and local candidates and single- candidate political campaign committees. A state candidate may not receive or expend funds for an election until a political treasurer has been appointed for that election. A local candidate pursuant to T.C.A 2-10-101, may be exempt from completing this form, please check with county election commission for more information. A candidate may appoint himself or herself as political treasurer. A new form must be filed if the treasurer is changed. Candidates for state public office must file their original Appointment of Political Treasurer statement ONLY with the Registry of Election Finance, 404 James Robertson Parkway, Suite 104, Nashville, TN 37243-1360. Candidates for local public office must file their original Appointment of Political Treasurer statement ONLY with their county election commission. 1. Date: 2. Candidate First and Last Name: 3. Candidate .e- ail add e (Cl cYC~ ro u, l 4. Ca paign ddress and Phone: City State Zip Code Phone 9 S S r~' v ~ lle 1 n ~~s 673 5. Home Address and Ph ne (if diffe ent than item 4 above): City tate Zip Code Phone 60-01k, 6 6. Office Sought (include district number, if applicable) 7. Party Affiliation 8. Election Year 01vr? a] #1 j s~ ~(,-,00&/ S ~0/ 9. Treasurer ame: 10. Treasurer e-mail address: cy-o we, ro tt)(~q 11. Treasurer Address and Phone: r City State Z Code Phone 7Z 3i5 sJ yA o(e Mor c v I D1~, Mn270A 6z'-It-7 12. Candida and Treasurer Si n re (both signatures must be witnesse easurer cannot witness candidate's signature): ReC~ ED JAN 2 4 2018 ature of Candidate 13LOUNTCO ignature of Treasure ELEC7ION~ Signature of Witness Signature of Witness Registry of Election Finance SS-1120 (rev 12/2013) FINANCIAL DISCLOSURE STATEMENT EXEMPTION Pursuant to TCA § 2-10-101(b) a candidate is exempt from filing financial disclosure statements due to the following: 1. The service for the office which I seek is part-time and the compensation is less than $1,000 per month, AND 2. 1 do not plan to spend more than $1,000 on my campaign. *Candidates running for Chief Administrative Officer (i.e. Mayor) of the county or city are NEVER exempt from filing and should file the required campaign financial disclosure reports regardless of compensation or spending. CANDIDATE'S INFORMATION: Candidate's Name: Dod J Candidate's Position: rAddress: S r1 CLAD City: Of L v 1 le- State TN Zi p: I hereby state that I meet the above qualifications for exemption and am therefore exempt from filing financial disclosure statements. If any of the above change and I no longer qualify as an exemption, I will file the required campaign financial disclosure reports with my local election commission. RECEIVED JAN 2 4 2018 I fie. 6 / Ca e' ignatur ELECTION Dat it ss's Signature Date CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT 2.a. NAME OF CANDIDATE OR COMMITTEE r t 2. i IF COTTjEE, NAME OF CANDIDATE n ,zj~` , 3. ELECTION DATE 4.a. CAMPAIGN ADDRESS AND P('HONEV Street or Rural Route City State Zip Code Phone 4.b. CANDIDATE'S H ME ADD SS (if different than 4.a.) Street or Rural Route City a - J&f7 State Zip Code Phone 5. OFFICE SOUGHT (include district number, if applicable) 6. NAME OF POLITICAL TREASURER (may be candidate) 7. CATEGORY OR REPORT (Check one) FIRST SF ❑ ❑ ❑ ❑ THIRD FOURTH PRE- 11 PRE- El QUARTER QUARTER QUARTER QUARTER PRIMARY MID-YEAR YEAR-END 8.a. BEGINNING DATE OF REPORTING PERIOD GENERAL SUPPLEMENTAL SUPPLEMENTAL S.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 be i f the didate or for any other nonpolitical purpose as defined by the federal internal revenue code. ature of candidate date / 1 n ignatur f political trea er d=ate 11. WITN SS SIGNATURE signature of witness date signature of witness date 12. SUMMARY a. BALANCE ON HAND LAST REPORT L 1 b. TOTAL RECEIPTS THIS PERIOD c. TOTAL DISBURSEMENTS THIS PERIOD $ _ _3 a l 3 f d. ovn O C ~ol BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) 179 $ 70 e. TOTAL LOANS OUTSTANDING 7~`L 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 &rn e _h) D , FROMq_ azj-/ 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.) $ 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) n $ Po $ ; c~c hLl $ $ $ $ $ Total of Expenditures $100 or less each payee) r b. Itemized Expenditures (Over $100 each payee this period) $ 19 too c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ 20. LOAN REPAYMENTS MADE THIS PERIOD $ (i ~1 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ 3 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 12.f.) $ 4) SS-1133 (Rev. 4/02) Page of V' ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD 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/Busi ess Name s , C\ V A C Q YI~Y AV. dress f l IN Ad L City Slate Zip Code lal V- 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 d Address City State Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City Stale Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/Business Name Address City State Zip Code 5. TOTAL ITEMIZED EXPENDITURES (Carry forward to item 3. of next page if additional pages of this form are used.) (If this is the last page of expenditures, this amount must be shown in item 19b. of summary:) SS-1129 (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. NAME OF CANDIDATE OR COMMITTEE 14 C:nmm~~Ee v l ba ld 1roW(2- 2.b IF COMMITTEE, 11E OF CANDIDATE 3. ELECTION DATE mod cal V O WQ- -mil ail ~l 4.a. CAMPAIGN ADDRESS AND PHONE Street or Rural Route City State Zip Code Phone off. w i 119 _TW O .8 7ya-(p 4.b. CANDIDATE'S HOME AD ESS (if different than 4.a.) Street or Rural Route City State Zip Code Phone 5. OFFICE SOUGHT (include district number, if applicable) B. NAME OF POLITICAL TREASURER (may be candidate) pUn ~.on►mtss~ona~'NA-Avi (D ""iSs LOVt 7. CA O ORY OR REPORT (Check one)❑ ❑ ~ ❑ ❑ ❑ FIRST SECOND THIRD FOUIRTH PRE- PRE- MID-YEAR YEAR-END QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8. a. BEGINNING DATE OF REPORTING PERIOD Tb. .ENDING DATE OF REPORTING PERIOD L~' 1 _ ap.r 4 4- a'~ - an 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.--R] 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. Uwe 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. Addifionally, IANe swear or affirm that no campaign contributions have been expended for the personal financial benefit of the candle or for any other nonpolitical purpose as defined by the federal internal revenue code. 4M U signature of candidate date ignature political tre er date 11. WI IES dg--nature ss date sign-afa o witness date 12. SUMMARY a. BALANCE ON HAND LAST REPORT .................1,,............... 5...,........ $ v C O 1. 130 b. TOTAL RECEIPTSTHIS PERIOD ..1U1.4'..............$ c. TOTAL DISBURSEMENTSTHISPERIOD ~v• $ 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 SUMMARY PAGE - CANDIDATE 13. NAME OF CANDIDATE OR COMMITTEE (In Full) 14. REPORT COVERING THE PERIOD Corn In i -e -f-C' L_e. J Jl7p~ C, FROM: _ I_ T0: _ a 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.) 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) t' V-i Y-4 t tnp $ t -0 3 L4. Dc-> $ $ $ $ $ $ Total of Expenditures ($100 or less each payee) $ C> b b. Itemized Expenditures (Over $100 each payee this period) $ '_G_ c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) $ 20. LOAN REPAYMENTS MADE THIS PERIOD $ -4~;) 21. TOTAL DISBURSEMENTS (add 19.c. and 20.) (must be shown in item 12.c.) $ 1) 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) $ c~ b. Itemized Obligations Outstanding (Over $100 each) $ y c. TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 12.f.) $ 4) SS-1133 (Rev. 4102) Page of CAMPAIGN FINANCIAL DISCLOSURE STATEMENT For State and Local Candidates For Single-Candidate Committees 1. DATE OF REPORT ' L 2.a. NAME OF CANDIDATE OR COMMITTEE h 1 `T um m,-4e_ uI e~~ ~x~c1 Crvitl2.b. IF COMMITTEE, NAME OF CANDIDATE 3. ELECTION DATE huda GrbWe_ 1'r0. e1 4.a. CAMPAIGN ADDRESS AND PHONE Street or Rural Route City State Zip Code Phone 4.b. CANDIDATE'S HOME ADDRESS (if fferent than 4.a.) I _j 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) &UA 1s 6 - i SS 7. CATEGORY OR REPORT (Check one) FIRST SECOND THIRD FOURTH P ❑ RE- P❑ ❑ ❑ RE- MID-YEAR YEAR-E ND QUARTER QUARTER QUARTER QUARTER PRIMARY GENERAL SUPPLEMENTAL SUPPLEMENTAL 8.a. BEGINNING DATE OF REPORTING PERIOD 8.b. ENDING DATE OF REPORTING PERIOD V ( 3 31-D' 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 candidate or for any other nonpolitical purpose as defined by the federal internal revenue code. ja~nl awe ~f 1 14 i _ CaIgnaiure of candidate date `sign re o politik i treasur r _ datel 11. NE ATURE sign of witness date si ature of witness date 12. SUMMARY a. BALANCE ON HAND LAST REPORT $ 0 C (D b. TOTAL RECEIPTS THIS PERIOD $ f{ (J . co c. TOTAL DISBURSEMENTS THIS PERIOD $ d. BALANCE ON HAND (12.a. plus 12.b. minus 12.c.) cJ e. TOTAL LOANS OUTSTANDING $ f. TOTAL OBLIGATIONS OUTSTANDING $ 4) SS-1109 (Rev. 2/06) Page 1 of RDA 1159 SUMMARY PAGE - CANDIDATE 133. NAME OF CANDIDATE OR COMMITTEE (In Full) 14. REPORT COVERING THE PERIOD WrY1~fY1i FROM: _ 1 1 T0: RECEIPTS 15. CONTRIBUTIONS (other than loans and interest) a. Unitemized Contributions ($100 or less from each source this period) $ 34D. cyo b. Itemized Contributions (over $100 from each source this period) $ 7rj~, > ,1 C. TOTAL CONTRIBUTIONS (other than loans and interest)(add 15.a. and 15.b.) $ V 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.) $ ( , QD 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) !'t,~uk Qum $ ob $ _W. c~ $ $ $ Total of Expenditures ($100 or less each payee) $ aq (p, b. Itemized Expenditures (Over $100 each payee this period) $ 1 LY~ rJ, co c. TOTAL EXPENDITURES (other than loan repayments)(add 19.a. and 19.b.) 20. LOAN REPAYMENTS MADE THIS PERIOD 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 Oeriod) $ 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) $ a TOTAL OBLIGATIONS OUTSTANDING (add 23.a. and 23.b.) (must be shown i item 12.f.) $ SS-1133 (Rev. 4102) Page of ITEMIZED STATEMENT OF EXPENDITURES - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD am m i ecd FROM: , _ TO: 3_ -I it 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/Business Name Address 0 fZ~S S City 3 Sta TIV te 3 ~ O First Name` Middle Name Purpose of Expenditure Amount of Expenditure Last ameBusiness t~ -Sh P ; uta . <z/--~ Addre I Pca d city State Zip Code `yla-r v i ( 140 3'`~ v3 First Name Middle Name Purpose of Expenditure Amount of Expenditure L ameBusi Name ri In !'i ng 3. ` ~ d CI y_ -kit Sfat Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last Name/eusiness Name x , Address 'P r'° l 1 City Stale Zip Code First Name Middle Name Purpose of Expenditure Amount of Expenditure Last NameBusiness Name Address city State Zip Code First Name Midge Name Purpose of Expenditure Amount of Expendflure Last Name/Business Name Address City State Zip Code 5. TOTAL ITEMIZED EXPENDITURES (Carry forward to item a of next page it additional pages of this form are used.) ' 1 '`T • C~ (if this is the lastpage of expenditures. this amount must be shown in item 19b. of summary) SS-1129 (Rev. 4102) Page of RDA 1159 ITEMIZED STATEMENT OF CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD CCNYItYI • FROM: -llc-1 T0. 3- 1- 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 a contributor) First Name Middle Name Contribution Received For: Amount of Contribution Lau g meror9anizaoon Name Primary Election ❑ General Election Addr s ©C- ❑ Runoff (Local Elections Only) ox It Of Ste ZipCode Date of Contribution Aggregate This Election Occupation 3-x--14 Employer Fig Name MidrdeName Contribution Received For: Amount of Contribution Last Name/Organization Name ❑ Primary Election ❑ General Election Address ❑ Runoff (Local Elections Only) city Stagy Zip Code Date of Contribution Aggregate This Election Occupation Employer First Name rid* Name Contribution Received For: Amount of Contribution Las[ ame garxzation Name Primary Election ❑ General Election Address Runoff (Local Elections Only) City Stare 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 Stare Zip Code Date of Contribution Aggregate This Election Occupation Employer 5. TOTAL ITEMIZED CONTRIBUTIONS (Carty forward to item 3. of next page if additional pages of this form are used.) 0f 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 ITEMIZED STATEMENT OF LOANS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: TO: 3. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED LOAN (loans totaling more than $100 from any source during the period) Complete the Following for the Source of the Loan First Name Middle Name Outstanding Loan Balance Loans Loan Outstanding Loan Balance (Beginning of Period) Received Payments (End of Period) Last Name/Organization Name Address Loan Received For: Date of can ❑ Primary Election ❑ General Election City Stale Zip Code ❑ 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 Stale Zip Code City Stale 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 Slate Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name Middle Name First Name Middle Name Last Name/Organization Name Last Name/Organization Name Address Address City State Zip Code City State Zip Code Amount Guaranteed Outstanding Amount Guaranteed Outstanding First Name 1 7 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.) (Total outstanding loan balance should also be shown in item 12.e. on front page.) CD SS-1132 (Rev. 4/02) Page of RDA 1159 ITEMIZED STATEMENT OF OBLIGATIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: TO: 3. COMPLETE THE APPROPRIATE ITEMS FOR EACH ITEMIZED Outstanding Balance Debt Incurred Payments Outstanding Balance OBLIGATION (obligations totaling more than $100 owed to any (Beginning of Period) This Period This Period (End of Period) person/vendor at the end of the reporting period) Flrst 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 Flrst Name Middle Name Last Name/Business Name Address e r u City State Zip Code Description of Obligation Flrst Name Middle Name Last Name/Business Name Address City State Zip Code Description of Obligation First Name Middle Name Last Name/Business Name Address City State Zip Code Description of Obligation 4. TOTALS (Total from Outstanding Balance - (End of Period) column must also be shown in item 23b. on summary page.) 4) SS-1127 (Rev. 4/02) Page of RDA 1159 ITEMIZED STATEMENT OF IN-KIND CONTRIBUTIONS - CANDIDATE 1. NAME OF CANDIDATE OR COMMITTEE 2. REPORT COVERING THE PERIOD FROM: TO: Amount 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 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 4 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,Conlrit ufion Received For: Value of In-Kind Contribution ❑ Fiimary Election E] 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 Lmployef 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 must be shown in item 22b. of summary.) (IJ SS-1128 (Rev. 2/06) Page of RDA 1159 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 off ice 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: (7Y-0 a) ~ Candidate's Position: Ylyli'vi-0 Toy-.r 1 Q'Yje ~ 60 U re-)~QQM Residential Address: l d v~h 5prlyl~u),-(f Lt) Rd City: mp-r ~1 V),6/ State' TN Zip: I hereby state that I meet the above qualifications for exemption and am therefore exempt from filing financial disclosure statements. Candidate's Signature Date Witness' ignature 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. ~ ~ .la1R FEB wd z~ ° 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 mself or herself as political treasurer. lA new form must be filed if the treasul er is changed. candidate may y appoint 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. 3. Candidate a all address: 1. Date: 2. Name of Candidate or Committee: 2 020/ " ~ e~ eiee- d z 4. C mpaign Address and Phone: City State Zip Code Phone 2 Q1 50 c, i~ S. Home Address and Phone differe an item 4 above): City ate Zip Code Phone . 6. ice Sought (include district number, if applicable) 7 Party Affliation 8. Election Year (h~ ~ C~ /~rrlr~sS"1 r' ~ ~U 6 r ~C r Z ~6 9. reasurer Name: 10. Treasurer a- mail address: Ci State Zip Code Phone 11. Treasurer Addr ss and Phone: ty 12. Candidate and Treasurer Signature (both signatures mu be witnessed. Treasu ercan not witness candidate's signature): Signature of CandidateSig nature of easurer Signature of Witness Signature of Witness Registry of Election Finance SS-1120 (rev 1012010)