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Home My WebLink AboutFinancial Rpt#2- Q2 - amended FLORIDA DEPARTMENT OF STATE Division CAMPAIGN TREASURER'S REPORT'$ilJM~RY , , ~ u' IdFFI~IJ~ ~LY U~ .... (1 ) J~ LibbM C~p~ '~.' :' ~:~'~'~ OFFICE Name (2) ]]2su. Sho~ ~. Addr~ (number and s~eM) ~ ~ach, ~ 33141-~ C~, ~e, ~P Code . ~ Ch~k ~x E addr~ h~ changed (3) I.D. Numar: ~0~ (4) Ch~k approp~Me ~x(~): X Candidate (offi~ ~ught): ~ami ~eh Ci~ Commi~,io~-~ou~ l ~ Pol~cal comm~ee ~ Ch~k E PC h~ DISBANDED ~ Comm~ of Continuous ~tence ~ Ch~k ff CCE h~ DISBANDED Pa~ ~ecu~e Comm~ee ~ El~oneefing Communi~on ~ Check ~ no o~er dec~onee~ng communic~on m~ ~11 ~ fil~ (5) REPORT IDENTIFIERS Cover Period: From 04/01/2~5 To ~/30/2~5 Re~d Ty~: ~Amendme~ ~ ,~ial Ele~on RepoA ~ Ind~endent ~nd~re Repod I 3figinal (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Mone~ C~h & Ch~ $20~148'~ ~nd~ur~ $8~481.58 Transfem to ~ce Loans $0.~ Account $0.~ T~I Mone~ $20~148.~ Total Mone~ $8,481:58 In-~nd $267.14 (8) ~her DMfib~ons $0.~ (9) TOTAL Moneta~ Contributions to Date (10) TOTAL Moneta~ Expenditures to Date $~,034.00 $12,178.87 (11 ) CERTIFICATION It is a first degree misdemeanor for any person to falsi~ a public re.rd (ss. 839.13, F.S.) I ce~ ~ I h~e examin~ th~ repod and ~ is I ce~ ~M I have ~amined ~ re~d and ~ is tree, ~rr~ and compete true, corr~t and com~Me J~ Libb~ ~ Libb~ ~ ,~ua, (~r ~ Tre~ur~ ~o~fi~ e~ng ~mun. ~an~) , , ,S re /', ' DS-DE 12 (Rev. 08K)4) Adjutant Software - Campaign ToolEk= /¥,,d' CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerry Libbin Campaign, (2) I.D. Number 00000 Cover Period 04/01/2005 - 06/30/2005 (4) Page 1 of 11 (5) (7) (8) (9) ( 1 O) (11 ) (12) Fu, ~m, Contributor (6) (Last, Suffix, First, Uiddle) In-kind Sequence Street Address & Contribution Number City, sta~e, ZipCode Type Occupation Type Description a~nendmenl Amount 04108/2005 Rodriguez, Tony I Investme CHE $ 250.00 1500 W. 24th St. nt Miami Beach, FL 33140-0000 Advisor 000001 04109/2005 Waxman, Eric I CHE $ 25.00 520 North Shore Dr. Miami Beach, FL 33141-0000 000002 04109/2005 Terranova Corporation B Bldg. CHE $ 500.00 Suite 600 Owner 801 Arthur Godfrey Rd. Miami Beach, FL 33140-0000 000003 04/09/2005 801 Arthur Godfrey Ltd. B Property CHE $ 500.00 Suite 600 Manage 801 Arthur Godfrey Rd. ment Miami Beach, FL 33140-0000 000004 04109/2005 Bittel, Stephen H. I Real CHE $ 500.00 Suite 1500 Estate 1200 Bdckell Ave. Investor Miami, FL 33131-0000 O0OO05 04/09/2005 Beach Towers LLC B Property CHE $ 500.00 Suite 500 Manage 801 Arthur Godfrey Rd. ment Miami Beach, FL 33140-0000 000006 04/21/2005 Simon, Ginette I Home CHE $ 250.® 2569 Lake Ave. Maker Miami Beach, FL 33140-0000 000007 04/21/2005 Nullman, Brenda I Home CHE $100.00 2523 Regatta Ave. Maker Miami Beach, FL 33140-0000 000008 DS-DE 13 (Rev. 08/03) Adjutant Soft~are - Campaign ToolBox/ CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerry Libbin Campa!~ln (2) I.D. Number 00000 f0112005 06130/2005 (4) Page ! of 11 (5) (7) (8) (9) (10) (11) (12) Full ~me Con~butor (6) (La~ S~x, Fi~ Middle) In-~nd ~n~fion ~uen~ ~t ~ & Ty~ O~u~on Ty~ ~cd~on ~endme~ ~ou~ Numar C~, ~, Zip ~ ~D1D005 Benrey, Oleva I T~cher CHE $ 50.~ 530 W. 5~h St. Miami Beach, FL 33140~000 000009 ~1D005 Softer, Mamha I Real CHE $ 250.~ SuEe 400 Estate 19~1 Bis~yne Blvd. Aventura, FL 33180-0000 000010 ~D1D005 Fri~, Neil I Administr CHE $100.00 1823 Jackson Strut 2 ator/muni Holl~ood, FL 33020~000 ci ~0011 ~1D005 Lombardi, Shad I Home CHE $ 50.00 1601 W. 28th St. Maker Miami Beach, FL 33140-0000 000012 ~D1D005 Off, Joe A. I Intedor CHE $ 50.~ 4816 Lakevi~ Dr. Decorato Miami Beach, FL 3314~000 r 000013 ~1D005 Leffon, Donald E. I D~elope CHE $ 200.00 Suite 500 r 3250 Ma~ St. Miami, FL 33133-0000 000014 ~D7D005 Malakoff, Joy I Banker CHE $100.00 ~15 Pinetr~ Dr. Miami Beach, FL 33141-0000 000015 ~7~005 Baum, Benjamin I Stock CHE $ ~100.00 Sure 27~ Broker 6301 Collins Ave. Miami Beach, FL 33141-0000 ~0016 DS-DE 13 (Rev. 08/03) Adjutant Software - Campaign ToolBoxj CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerr~ Libbin Campai~ln (2) I.D. Number 00000 ' Period 04101/2005 - 06/30/2005 (4) Page 3 of 11 (5) ~) (8) (9) (~o) (~ 1) (12) F., ~ Con~b~or (~) (La~ Su~x, Fi~ M~) In-~nd ~uen~ ~t ~m~ & ~n~n Numar C~, ~a, zip ~ Ty~ ~u~on Ty~ ~on ~endme~ ~ou~ ~DTD005 EMF & Associates, Inc. B Governm CHE $ 500.00 Sure ~0 ent 9100 South Dadeland Blvd. ConsuEa Miami, FL 331~7815 n ~0017 ~D7D005 Baum Chimpm~ic Clinic, P.A. B Chiroprac CHE $100.00 1175 71st ST. tor Miami Beach, FL 33141-~45 000018 ~9~005 Russ, Ri~ard i CHE $ 25.00 2800 Sus~ Dr. Miami Beach, FL 3314~00 ~0019 ~gD005 Kaplan, Ma~ I CHE $ 50.00 5500 Collins Avenue Miami B~ch, FL 3314~0000 ~020 05101~005 Rosen, Do~s I R~ir~ CHE $100.00 ~t. ~so3 ~00 Collins Ave. Miami B~ch, FL 3314~2501 000021 0~01D005 Jaffe, Bemi~ I Retir~ CHE $ 25.00 ~t. 2414 9 Island Ave. Miami Beach, FL 33139-0000 ~0~2 0~0~005 Singer, Bru~ i Administr CHE $ 250.~ ~61 Pin~r~ Dr. ator Miami Beach, FL 33141-0000 ~0023 05/0~005 Shnayemon, Robe~' I Shopping cHE $100~00" 5750 Collins Av~ue Center- Miami Beach, FL 3314~0 ~ns ~0024 ~ 13 (Rev. Adjutant Software - Campaign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerry Libbin Campai~ln (2) I.D. Number 00000 !005 06/30/2005 (4) Page 4 of 11 (5) ~) (8) (9) (10) (11) (12) F~, ~m Con~butor ~uen~ S~t A~ & ~n~n Numar C~, ~, Zip ~ Ty~ ~on Ty~ ~on ~endme~ ~ou~ ~1~005 Levine, Hawey I Interior CHE $100.00 2430 N. Shore Ter. D~rato Miami Beach, FL ~141-0000 r O0O025 ~1~005 Hernand~, Oscar I Busings CHE $100.00 Apt. 15 ConsuEa 1685 Je~rson Ave. nt Miami B~ch, FL 33139-0000 ~026 05/~D005 Aizens~t, Nicolas I D~elope CHE $ 200.~ Apt. 310 r 8777 Collins Ave. Su~ide, FL 331~08 ~0027 05/~D005 ~enstat, Natan I ~chit~ CHE $ 2~.00 Apt. 401 21075 NE ~th Ave. Aventura, FL 33180-3~0 000028 0~D005 SpOor, ShiHey I R~ir~ CHE $100.~ ~t. 17-D ~0 Collins Ave. Miami Beach, FL 3314~000 ~0029 05/~005 Schaffer, Richard I R~I CHE $ 250.00 P.H. A Estate ~00 Collins Ave. De, ope ' ' ' Miami Beach, FL 3314~000 00~30 n ............... 0~005 Aug, ChaHes I ~s CHE $ 200.00 1900 Sunset Ha~our Dr. Shopping Miami B~ch, FL 33139-0000 Center ~0031 05/~005 Homstein, 'Frank ' ' I Apparel CHE $100.00 9819 N.E. 4th A~. Rd. Miami Shores, FL 331~0000 ~0032 DS-DE 13 (Rev. 08~03) Adjutant Software - Campaign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerr~ Libbin Campaign (2) I.D. Number 00000 Cover Period 04101/2005 - 06130/2005 (4) Page 5 of 11 (5) (7) (S) (9) (10) (11 ) (12) Fu, Name Contributor (6) (Last, Suffix, First, Middle) I n-ldnd Sequence S'a'eet Address & Contribution Number City, Sta~e, Zip Code Type Occupation Type Description ~endmenl Amount 05/06/2005 Bercow, Julie I Home CHE $ 500.00 590 Lakeview Drive Maker Miami Beach, FL 33140-2648 000033 05/06/2005 Kasdin, Ana I Teacher CHE $ 500.00 4520 N. Jefferson Ave. Miami Beach, FL 33140-0000 000034 05/10/2005 Green, Marcia I Retired CHE $ 300.00 2525 Lucerne Miami Beach, FL 33140-0000 000035 05/10/2005 Gumenick Management Co. LLC B Property CHE $ 500.00 P.O. Box 17038 Manage Richmand, VA 23226-0000 ment 000036 05/12/2005 Gelber, Judith I Teacher CHE $100.00 865 Fairway Dr. Miiami Beach, FL 33141-0000 000037 05/12/2005 Gelber, Edith I Retired CHE $ 50.00 No. 1408 20 Island Ave. Miami Beach, FL 33139-0000 0O0038 05/12/2005 Hunter ~nd Hunter R~ruiting, Inc. 'B I=mploym CHI= $100100 8t~. 11 ent 3929 Meridian Ave. Agency Miamii Beach, FL 33140-0000 000039 05/12/2005 Firschein, Shirley I Retired CHE $100.00 6-P 7441 Wayne Ave. Miami Beach, FL 33141-2502 000040 DS-DE 13 (Rev. 08J03) Adjutant Sofl~are - Campaign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerry Libbin Campai~ln, (2) I.D. Number 00000 ' Period 04101/2005 - 06130/2005 (4) Page 6 of 11 (5) (7) (8) (9) (10) (11) (12) Fu, ~ Con~butor (6) (La~ S~x, F~ M~) I~nd ~uen~ ~t Add~ & ~n~n Numar C~, ~, Zip ~ my~ ~on my~ D~ ~endme~ ~ou~ 05/1~005 Nhadeff, Meme I Home CHE $ 250.~ 715 N. Shorn Dr. Maker Miami Beach, FL 33141-0000 ~0~1 0511~005 So~h B~ch R~o~ Development, B Develope CHE $ 300.00 LLC r 1458 Ocean Dr. Miami Beach, FL 33139~000 0~2 0~15~005 Singer, David I AEomey CHE $ 200.00 7~ Lakevi~ Dr. 200.00 Miami Beach, FL 3314~000 ~3 05/16~005 Rose, Fmncine I Retir~ CHE $ 200.00 205 Fairy Dr. Miami B~ch, FL 33141-0000 ~0~ 05/19~005 Klinger, Michelle I Homema CHE $ 500.~ 200~ N.E. ~h Pla~ ker Aventura, FL 33180-3074 ~0~5 05/19~005 Caff~, Claudia I Teacher CHE $ 500.~ 19452 N.E. ~h Ave. ~1 Aventura, FL 3318G~23 000~ 05/19~005 Sternstein, David I CHE $15.00 2301 Collins Ave. Miami Beach, FL 33139-00~ 000~7 05119~005 Banner,' Patrick I Medi~l CHE $ 500.~ 400 N. Commodore Dr. ~02 epuipme Plantation, FL 3332~0000 nt ~0~8 (Rev. 08/03) Adjutant Software - O~mp~ign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerry Libbin Campai~ln (2) I.D. Number 00000 04/01/2005 - 06130/2005 (4) Page 7 of 11 (5) ~) (8) (9) 0 o) 0 ~ ) 0 2) FU~ Na~ Con~b~or (6) ' (La~ Suffix, Fi~ M~d~) I~nd 05119~5 Bati~sky, Mark I Constm~ CHE $ 500.00 20031 N.E. 21 Ct. ~on N. Miami Beach, FL 3317~000 000~9 05119~005 Baca, Joseph I CHE $ 25.00 2301 Collins Ave. · 805 Miami B~ch, FL 3313~1601 ~0050 05119~005 C~p~as, Carolina I S~reta~ CHE $ 500.00 530 N.E. 131 St ST. N. Miami, FL 33161-7714 ~0051 05/19~005 Zillemelo, Lor~o I Media CHE $ 500.00 10295 Collins Ave. ~17 Bal Ha~or, FL 331~0 ~0052 05/19~005 B&B Lim~, LLC B Constru~ CHE $ 500.~ 219 7th ~. ion Miami Beach, FL 3313~ ~0053 05119~5 Marc K. Wein~rg DC, PA DBA~ B Chiroprac CHE $ 5~.00 Chimpra~ic Center tor 1352 N.E. 163rd ~. N. Miami Beach, FL 33162~23 0~0~ ~19~5 Cohen, ~ephan i CHE $ 25'.® ~e. 201 801 ~hur ~dffey Rd. Miami Beach, FL 3314~000 ~055 05119~005 Bild, Nff~o '~Realtor CHE ' ' $ '250.~ ~0 S.W. 11~h St. Miami, FL 3317~000 ~00~ DS-DE 1:3 (Rev. Adjutant Software - Campaign ToolBoxj CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerry Libbin Campai~ln (2) I.D. Number 00000 !005 - O6/30/2005 (4) Page 8 of 11 (5) ' (7) (8) (9) (1 O) (11 ) (12) Full Name Contributor (6) (Last, Suffix, FIRM, Middle) In-kind SequenCe Street Address & C, on~bution Number City, State, Zip Code Type Occupation Type Desc~l~on ~,mendmenl Amount 05/19/2005 Scemla, Sandra I Owns CHE $ 500.00 210 Ocean Blvd. ~etail Golden Beach, FL 33160-0000 Store 000057 05/19/2005 Real Estate Related LLC B Mortgage CHE $ 500.00 35 NE 38th St. Compan Miami, FL 33137-0000 Y 000058 05/19/2005 Johnny Rocks Fitness Center B Fitness INK food/drinks $ 267.14 2301 Collins Ave. Center /paper Miami Beach, FL 33139-0000 good 000059 05/27/2005 Newman, Robert I CHE $ 25.00 Apt. 3006 650 West Ave. Miami Beach, FL 33139-6372 000060 06107/2005 Freytech, Inc. B CHE $ 50.00 ~79th St. Miami Beach, FL 33139-0000 000061 06/07/2005 Wein, Jr., Leonard I Real CHE $ 500.00 925 Arthur Godfrey Rd. Estate Miami Beach, FL 33141-0000 Investme 000062 06/07/2005 Linowitz, Marc I Attorney CHE $ 200.00 Suite 404 900 Bay Dr. " Miami Beach, FL 33140-0000 000063 06110/2005 Edgewater Studios, LLC B " Phot0gra ~HE $ 250.00 423 N.E. 23rd St. phic Miami, FL 33137-0000 Studio O00064 D~.-DE 13 (Rev. 08/03) Adjutant Soltwam - Campaign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name , Jerry Libbin Campai~ln (2) I.D. Number 00000 od 04/01/2005 - 06/30/2005 (4) Page 9 of 11 (5) (7) (8) (9) (10) (11 ) (12) Fa, N~me Contributor (6) (Last, Suffix, First, Middle) In-kind Sequence Street Address & Cont~utJon Number City, State, Zip Code Type Occupation Type Description a~nendment Amount .... 06/10/2005 643 Jefferson Avenue, Inc. B Apartmen CHE $ 250.00 423 N.E. 23rd St. t Bldg. Miami, FL 33137-0000 000065 06110/2005 Barcelona Hotel, LLC B Real CHE $ 500.00 423 NE. 23rd St. Estate Miami, FL 33137-0000 Company 000066 06/11/2005 Moss, Morey I Florist CHE $100.00 PH A 5660 Collins Ave. Miami Beach, FL 33140-0000 O0O067 06116/2005 Bloom, Elaine I Retired CHE $100.00 5255 Collins Ave. #3-J Miami Beach, FL 33140-0000 0O0068 06/16/2005 Dominguez, Carlos I Doctor CHE $100.00 Apt. 1603 300 S. Pointe Dr. Miami Beach, FL 33139-0000 000069 06118/2005 Willins, Hardet I Retired CHE $10.00 Apt. 309 B 39B 1st St. Worcester, MA 01602-0000 000070 06/18/2005 Willi 'ns, Terry I 'CHE $18.00 5 Hagen Rd. Newton, MA 02459-1612 000071 06118/2005 'Aaron, Harvey I ' CHE $ 5.00 5 Hagen Rd. Newton, MA 02459-0000 000072 DS-DE 13 (Rev. 08/03) Adjutant Software - Campaign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerry Libbin Campaign (2) I.D. Number 00000 (3) Cover Period 04101/2005 - 06/30/2005 (4) Page 10 of 11 (5) (?) (8) (9) ( 1 O) (11 ) (12) Full Name Contributor (6) (Last, Suffix, Fimt, Middle) In-kind Sequence Street Address & Confl'ibution Number City, State, Zip Code Type Occupation Type Descdplion ~mendmen~ Amount 06/21/2005 Angler's Resort, LLC B Hotel CHE $ 500.00 Suite 300 2800 Biscayne Blvd. Miami, FL 33137-4500 000073 06/22/2005 Kramer & Associates, P.A. B Accounta CHE $ 500.00 4225 Ponce De Leon Blvd. nts Coral Gables, FL 33146-0000 000074 06/24/2005 Hoffman, Carol I CHE $ 50.00 4740 Alton Rd. Miami Beach, FL 33140-0000 000075 06/27/2005 Schmuger, Steve I Graphic CHE $150.00 1050 North Shore Dr. Pdnter Miami Beach, FL 33141-0000 000076 06/28/2005 Ocean Washington Associates, LTD B Income CHE $ 500.00 230 5th Street Propertie Miami Beach, FL 33139-0000 s 000077 06/28/2005 Espanola Way Associates B Income CHE $ 500.00 230 5th St. Property Miami Beach, FL 33139-0000 000078 06/28/2005 Mccrory AssoCiates, LTD. B Income CHE $ 500.00 230 5th St. Property Miami Beach, FL 33139-0000 000079 06/29/2005 Devon Apartments, Inc. B Rentai CHE" $ 250.00 P.O. Box 403143 Apartmen Miami Beach, FL 33140-0000 ts 000080 DS-DE 13 (Rev. 08J03) Adjutent Software - Campaign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name Jerry Libbin Campai~ln (2) I.D. Number 00000 04101/2005 06130/2005 (4) Page 11 of 11 (5) (7) (8) (9) (10) (11 ) (12) Full Name Contributor (6) (Last, Suffix, First. Middle) In-kind sequence stn~et Address & Contribution Number City, State. Zip Code Type Occup~on Type De,clip, on e~endmer~ Amount 06/29/2005 Somar Realty, Inc. B Rental CHE $ 250.00 5572 Pine Tree Dr. ^partmen Miami Beach, FL 33140-0000 ts 000081 06/29/2005 Rubinson, Jaime I Attorney CHE $ 500.00 1440 West 21 St. Miami Beach, FL 33140-0000 000082 DS-DE 13 (Rev. 08/03) Acljutent Software o Campaign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name Jerry Libbin Campaign (2) I.D. Number 00000 Cover Period 04/01/2005 - 06/30/2005 (4) Page I of I (5) (7) (8) (9) (10) (11) Full Name (6) "' (Last, Suffix, Firs~ Middle) Purpose Sequence Street Address & (add o~ce sought if Expenditure Number City, State, Zip Code contribution to a candidate) Type ~mendment Amount 04/03/2005 Adjutant Software Reporting software MON $120.00 2055 Bond Road DeLand, FL 32720-4531 04/06/2005 The Donner Group Consulting MON $ 4,062.50 7525 SW 54th CT. Miami, FL 33143-0000 000002 04/26/2005 City of Miami Beach Records request MON $ 51.00 1700 Convention Center Dr. Miami Beach, FL 33139-0000 000003 05109/2005 The Donner Group consulting plus MON $1,633.47 7525 SW 54th Ct. expenses Miami, FL 33143-0000 000004 05/23/2005 Artistic Images Make-UP Make- u p for Photo MON $150.00 5850 SW 9th Terrace West Miami, FL 33144-0000 000005 05/23/2005 Greg Hark Photographics Campaig Photograph MON $ 856.00 6340 Pine Tree Dr. Miami Beach, FL 33140-0000 000006 06106/2005 Colonial Bank bank charge M0N $ 8.00 P.O. Box 1887 Birmingham, AL 35201-1887 000007 06/20/2005 The Donner Group COnsulting 'plus MON $1,600.61' 7525 SW 54th CT. expenses Miami, FL 33143-0000 000008 O~-DE 14 (Rev. 08/03) Adjutant Software - Campaign ToolBox CAMPAIGN TREASURER'S REPORT - ITEMIZED DISTRIBUTIONS THIS FORM APPLIES TO P(X.I*TtC/~ COMMITTEES, COMMITTEES OF CONTINUOUS EXISTENCE AND PARTY EXECUTIVE COMMITTEES ONLY. (1) Name Jerry Libbin Campai~ln (2) I.D. Number 00000 (3) Cover Pedod 04/01/2005 - 06130/2005 (4) Page 0 of 0 (5) (7) (8) (9) (10) (11) , , Full Name (6) (Last, Suffix, First, Middle) Purpose Sequence St~et Address & (add o~lce sought if Related Number City, State, Zip Code contribution to a candidate) Expenditures Amendment Amount Nothing to report on t lis form DS-DE t4A (Rev. 08/03) Adjutant Software - Campaign ToolBox CAMPAIGN TREASURER'S REPORT - FUND TRANSFERS (1) Name Jerry Libbin Campaign (2) I.D. Number 00000 (3) Cover Period 04101/2005 - 06/30/2005 (4) Page 0 of 0 (5)" (7) (8) (9) (10) (11) Name of Financial (6) Inst;tution Transfer Nature of Sequence Street Address & Number City, State, Zip Code Type Account ~nendment Amount Nothing to report on th s lorn DS-DE 94 (Rev. 08/03 Adjutant Software - Campaign ToolBox