DS-DE 12 G1-11 Urquiza FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAM AIGN TREASURER'S REPORT SUMI Y \./
(1) L-- i , G� v --C� OFFICE USE ONLY
Name 2011 SEP 30 PM 12: 1 I
( � � - /✓U 4 /4 CLERK'S �l CITY ,L��� OFFICE �� �
Ad ess (num er and stree
AG /1/ , 3g13
City, State, Zip Code
❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number:
(4) Ch9,ek appropriate box(es): CO gCCandidate (office sought): (.� 227 ? SS i o Y7 c / —
U Political Committee ❑ CHECK IF PC HAS DISBAN ED
❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED
�f Party Executive Committee
7 Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Cover Period: From / ( / Zoi l To q / / ? Report Type 6/ .41
[f Original II] Amendment ❑ Special Election Report El Independent Expenditure ! Report
(6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT
Monetary
Cash & Checks $ Expenditures $
Loans $
Transfers to Office
Account $
Total Monetary $ Total
• Monetary $
In -Kind $
(8) Other Distributions ,/
(9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date
$ 5, OCX) . aO $ s
(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) : d „; C 6 , 4 1c (Type name) j" /5/3 / `'a � i z,—
❑individuai (only or v
y � T reasurer El Treasurer Candidate Chairperson (only for PC, PTY &
electioneering commun) lectioneering commun. organization)
Z,J
Signature Signature
DS -DE 12 (Rev. 08/04)
P eLs-c f