R1 10/28/11 to 11/10/11 Campaign Treasurer's Report FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
OFFICE USE ONLY
(1) Citizen Action,Inc.
Name
(2) 7525 SW 54th Ct
Address(number and street)
Miami,FL 33143
City,State,Zip Code
❑ Check box if address has changed
(3) I.D.Number: 55388
(4) Check appropriate box(es):
Candidate(office sought):
Political Committee ❑ Check if PC has DISBANDED
Committee of Continuous Existence
❑ Check if CCE has DISBANDED
Party Executive Committee
X Electioneering Communication ec<I no of er electioneering_communication-reports-will-beJiled
(5) REPORT IDENTIFIERS
Cover Period: From 10/28/2011 To 1 1/10/201 I Report Type:
❑X Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT
Monetary
Cash&Checks $20,000.00 Expenditures $35,255.02
Transfers to Office
Loans $0.00 Account $0.00
Total Monetary $20,000.00 Total Monetary $35,255.02
In-Kind $0.00 (8)Other Distributions $0.00
(9) TOTAL Monetary Contributions to Date (10) TOTAL Monetary Expenditures to Date
$156500.00 $136,772.42
(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 I certify that I have examined this report and it is
true,correct and complete true,correct and complete
Keith Donner Keith Donner
❑ Individual(only for ❑ Treasurer ❑ Deputy Treasurer ❑ Candidate ❑ Chairman(only for PC.PTY 8
electioneering }( X electioneer' commun.organization)
commun.)
X __L_;,� X ^�
Signature Signature
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CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name Citizen Action, Inc. (2) I.D. Number 55388
(3)Cover Period 10/28/2011 - 11/10/2011 (4) Page 1 of 1
(5) (7) (8) (9) (10) (11) (12)
Date
Full Name Contributor
(6) (Last,Suffix,First,Middle)
Sequence Street Address& Contribution In-kind
Number City,Stale,Zip Code Type Occupation Type Description Amendmeni Amount
11/10/2011 The Democracy Project Inc. C CCE CHE $
7525 SW 54th Ct 20000.00
Miami, FL 33143-0000
1
This form is based on DS-DE 13(Rev.08/03) Adjutant Software,Inc.-Campaign ToclBox
7
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
(1) Name Citizen Action, Inc. (2) I.D. Number 55388
(3)Cover Period 10/28/2011 -11/10/2011 (4) Page 1 of 2
(5) (7) (8) (9) (10) (11)
Date
Full Name
(6) (Last,Suffix,First,Middle) Purpose
Sequence Street Address 8 (add office sought if Expenditure
Number City,State,Zip Code contribution to a candidate) Type Amendmeni Amount
10/28/2011 America CV Network Advertising MON $1827.50
13001 NW 107th Ave
Hialeah Gardens, FL 33018-0000
1
11/10/2011 America CV Network Advertising MON $3102.50
13001 NW 107th Ave
Hialeah Gardens, FL 33018-0000
2
11/10/2011 America CV Network Advertising MON $43.00
13001 NW 107th Ave
Hialeah Gardens, FL 33018-0000
3
11/10/2011 Univision TV Advertising MON $3000.00
8550 NW 33rd St
Miami, FL 33122-0000
4
11/10/2011 50 Blue LLC Advertising MON $ 1742.95
7525 SW 54th Ct
Miami, FL 33143-0000
5
11/10/2011 50 Blue LLC Advertising MON $8525.00
7525 SW 54th Ct
Miami, FL 33143-0000
6
11/10/2011 The Donner Group Expenses MON $2202.28
7525 SW 54th Ct
Miami, FL 33143-0000
7
11/10/2011 The Donner Group Expenses MON $2778.14
7525 SW 54th Ct
Miami, FL 33143-0000
8
This form is based on DS-DE 14(Rev.0 8/03) Adjutant Software,Inc.-Campaign ToclBox
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
(1) Name Citizen Action, Inc. (2) I.D. Number 55388
(3)Cover Period 10/28/2011 - 11/10/2011 (4) Page 2 of 2
(5) (7) (8) (9) (10) (11)
Date
Full Name
(6) (Last,Suffix,First,Middle) Purpose
Sequence Street Address 8 (add office sought if Expenditure
Number City,State,Zip Code contribution to a candidate) Type Amendmeni Amount
11/10/2011 50 Blue LLC Advertising MON $12033.65
7525 SW 54th Ct
Miami, FL 33143-0000
3 9
This form is based on DS-DE 14(Rev.08/03) Adjutant Software,Inc.-Campaign ToolBox
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CAMPAIGN TREASURER'S REPORT - ITEMIZED DISTRIBUTIONS
(1) Name Citizen Action, Inc. (2) I.D. Number 55388
(3)Cover Period 10/28/2011 -11/10/2011 (4) Page 0 of 0
(5) (7) (8) (9) (10) (11)
Date
Full Name
(6) (Last,Suffix,First,Middle) Purpose
Sequence Street Address& (add office sought if Related
,1 Number City,Slate,Zip Code contribution to a candidate) Expenditures Amendmeni Amount
Nothing to report on this form
This form is based on DS-DE 14A(Rev.08/03)[Note about Committees has been removed.] Adjutant Software,Inc.-Campaign ToolBox
CAMPAIGN TREASURER'S REPORT - FUND TRANSFERS
(1) Name Citizen Action, Inc. (2) I.D. Number 55388
(3)Cover Period 10/28/2011 -11/10/2011 (4) Page 0 of 0
(5) (7) (8) (9) (10) (11)
Date
Name of Financial
(6) Institution Transfer Nature of
Sequence Street Address&
Number City,State,Zip Code Type Account Amendmeni Amount
Nothing to report on this for
This form is based on DS-DE 94(Rev.08/03) Adjutant Software.Inc.-Campaign ToolBox