DS-DE 12 Urquiza Q4-11 FLORIDA DEPARTMENT OF STATE DIVISION OF.ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) ,ISc� 04'to Z U OFFICE USE ONLY
Name
(2) ZZ.- Z Q,vn A-\4D a-
A ddress (number and street)
A A v1' 8 cc,0,1 1 1 331 iKcA
City, State, Zip Code
❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number:
(4) Ch5ak appropriate box(es):
Candidate (office sought) C-00,1v ass, 0vter G-,r000 I
❑ Political Committee ❑ CHECK IF PC HAS DISBANDED
❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED
❑ Party Executive Committee
Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Coy Period From its / 1 / 2011 To IL / 3 I / 2(.911 Report Type 04-k\
Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT
Monetary
Cash'8, Checks $ Expenditures $ pl CD o
N
Loans $ � Transfers to Office c-, ;7
Account $ j ,T x' 0
Total Monetary $ � j Total `D ��
J" Monetary $ ( "' =
( �'
In-Kind $ -n r
(8) Other Distributions rT cwn
$
(9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.)
I certify that I have examined this report and it is true, I-certify that I have examined this report and it is true,
correct, and corn�plete correct, and corn plet/ )
(Type name) �-�!w�f 1 Cc .. (Typ name) s4 /4 , C/J�'4.C.)l Z�.
['Individual(only for Treasurer ❑Deputy Treasurer Candidate ❑Chairperson(only for PC,PTY&
electioneering commun.) plectio eying commun.organization)
X ` c
■
Signature Signature
DS-DE 12(Rev.08/04) V