DS-DE 12 Urquiza Amended , /-11116 A/DE D
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) f . L ,,, 17t ' G J j ZGL OFFICE USE ONLY
Name / N
(2) 22 7 F, j"j "'I l h DI.
Address (number and street) - . �
/V, I.:) f / --, ) / , c
City, State, Zip Code rri 01 '
❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: v� .,
( 4) Check appropriate box(es): �, ,.
['`Candida (o ffice sought): L G » ») 2)/,Ss �'v 27Cl', '',,
y =-; N
n Political Committee ❑ CHECK IF PC H A DISBANDED
❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED
❑ Party Executive Committee
❑ Electioneering Communication LJ CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Cover Period: From G , / ,O / / \�i, To cc / 3 6 / c2/ Report Type (c
❑ Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT
Monetary
Cash & Checks $
Expenditures $
Loans $ �', Ca) , at Transfers to Office
Account $
Total Monetary $ O Total
Monetary $f
In -Kind $ 0
(8) Other Distributions
$ V
(9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date
$ , COO - CC) $
(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) Cd 4 f d Co y r(�3 (Type name '
❑Individual (only for QTreasurer 0 Deputy Treasurer 1111 Candidate ❑ Chairperson (only for PC, PTY &
electioneering commun.) ( electioneering commun. organization)
X f
Signature -� --° Signature ( r
DS -DE 12 (Rev. 08/04)