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DS-DE 12 F4-09 SeguiFLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY N (1) D~ ~ ~ ~ 0„9 OFFICE USE~NLI~ ' Name ~ ~ e 1 ~~.~'. ~+ ~°'~ ° ~- ~- Address (number and str et) ._, ~, -o City, State, Zip Code ~ •' ^ CHECK IF ADDRESS HAS CHANGED r (3) ID Number: T"' (4) Check appropriate box(es): ~ Candidate (office sought): ~(OJ 1 ^ Political Committee ^ CHECK IF PC HAS DISBANDE ^ 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 Cover Period: From /lJ / lp l ~ To l('~ l y`~ y' l ©c/ Report Type ~lf~ t Original ^ Amendment ^ Special Election Report ^ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Cash & Checks $ ~ Monetary Expenditures $ ~' Loans $ .~~ Transfers to Office Account $ ~~~ Total Monetary $ ~ Total Monetary $ ~~ In-Kind $ ~ (8) Other Distributions//~~ ~ 4~ $ - t (9) TOTAL M etary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ ~ x~ $ (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 complete. correct, and complete. (Type name) ~~ ~~ Q ~ (Type name) ~~ J °~-'l ^individuai (only for r Deputy Treasurer electioneering commun ^ Candidate n (only for PC, PTY & el i ne g c mun. organization) X X Signature Signatur D5-DE 12 (ReV. 08/04) /~i4~`~ ~ ~--, i CAMPAIGN TREASURER'S REPORT -ITEMIZED CONTRIBUTIONS (1) Name ~ ~ ~" . (2) I.D. Number (3) Cover Period ~~ / ~ / Q~ through l~ / ~~ / ~ (4) Page of (5) Date (7) Full Name (8) (9) (10) (11) (12) (8) Sequence Number (Last, Suffix, First, Middle) Street Address & Ci ,State, Zi Code Contributor T e OCCU ation Contribution T e In-kind Descri tion Amendment Amount / / . ~~ ~/ ~ r i i i i i i i i i i i i i ua-u~ ~s ~rtev. uaius- SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES ~y-~c ~ ~ 3 MPA~N TREASURER'S REPORT -ITEMIZED EXPENDITURES (1) Name ® ~ ~/ (2) I.D. Number (3) Cover Period ~/~/~ through ~/~/~ (4) Page of (5) Date (~) Full Name ($) Purpose (9) (~~) (~~) (s) Sequence Number (Last, Suffix, First, Middle) Street Address 8~ City, State, Zip Code (add ofFice sought if contribution to a candidate) Expenditure TYPe Amendment Amount us-Ut 74 (KeV. 0ti/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES ~~~ 3 ~ 3