Professional Documents
Culture Documents
SEEC FORM 20
Itemized Campaign Finance Disclosure Statement
CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION
Revised January 2015
Page 1 of 26
COVER PAGE
1. NAME OF COMMITTEE
Ansonia Republican Town Committee
2. TREASURER NAME
First
Linda
MI
Last
Vaccaro
Suffix
3. TREASURER ADDRESS
Street Address
City
State
Zip Code
515 Beaver St
Ansonia
CT
06401
4. ELECTION/REFERENDUM DATE
MI
Last
Suffix
8. TYPE OF REPORT
October 10 Filing - Original
9. PERIOD COVERED
Beginning Date
07/01/2015
Ending Date
thru
09/30/2015
10. CERTIFICATION
I hereby certify and state, under penalties of false statement, that all of the information set forth on this
Itemized Campaign Finance Disclosure Statement for the period covered is true, accurate and
complete.
Electronic Filing
Linda Vaccaro
10/09/2015
7:37:19PM
SIGNATURE
DATE CERTIFIED
A Person who is found to have knowingly and willfully violated any provisions of the campaign finance statutes faces a civil
penalty or imprisonment or both.
Page 2 of 26
SEEC FORM 20
Itemized Campaign Finance Disclosure Statement
CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION
Revised January 2015
TYPE OF REPORT
October 10 Filing - Original
COLUMN A
COLUMN B
This Period
Aggregate
11. Balance on hand January 1 of current year for Ongoing and Party Committees OR
Balance on hand from day Committee was formed for all other Committees
$1,774.85
$2,699.85
$6,454.00
$7,654.00
$250.00
$250.00
$2,496.00
$2,496.00
$0.00
$0.00
16b. Per Public Act 11-48, effective January 1,2012 Section L2 removed
16c. Total Purchases of Advertising - Program Book or Sign (Section L3)
17. Total Monetary Receipts (add totals for lines 13 through 16c)
18. Subtotals (add totals in Line 12 + 17 in Column A and in Line 11 + 17 in Column B)
19. Expenses Paid by Committee (Section P)
20. Balance on hand at close of Reporting Period (Subtract line 19 from line 18 in both colum
21. In-Kind Donations not Considered Contributions Received (Section L4)
22. In-Kind Donations not Considered Contributions - House Party (Section L5)
23. In-Kind Contributions Received (Section M)
24. Refundable Deposit to Telephone Company (Section N)
25. Loan Balance
$0.00
$0.00
$9,200.00
$10,400.00
$11,899.85
$12,174.85
$10,981.09
$918.76
$0.00
$0.00
$11,256.09
$918.76
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Page 3 of 26
TYPE OF REPORT
$0.00
Subtotal Section A
First Name
Radin
Residential Street Address
Ansonia
Principal Occupation
Yes
No
Yes
No
Executive
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Aggregate Contributions
07/23/2015
$200.00
$200.00
MI
Irving
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Quality Mgr
Yes
No
_
X
Yes
No
Executive
Method of Contribution
X
City
14 Highland Ave
_
_
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
07/23/2015
$100.00
$100.00
First Name
Vaccaro
MI
Lorie
City
515 Beaver St
Ansonia
Principal Occupation
State
Zip Code
CT
96488
Name of Employer
Retired
none
Yes
No
Yes
No
Personal Check
Executive
Method of Contribution
Cash
06401
First Name
Reed
_
_
Date Received
Last Name
Cash
Method of Contribution
Zip Code
CT
Lear Pharmacey
State
Name of Employer
Pharmacist
Cash
City
MI
Joan
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
08/09/2015
Aggregate Contributions
$500.00
$500.00
Page 4 of 26
TYPE OF REPORT
First Name
Fers
Residential Street Address
Ansonia
Principal Occupation
Yes
No
_
X
Yes
No
Executive
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Aggregate Contributions
08/09/2015
$50.00
$50.00
MI
Sheila
Oakville
Principal Occupation
State
Zip Code
CT
06779
Name of Employer
Grant Writer
City of Ansonia
Yes
No
Yes
No
Executive
Method of Contribution
X
City
_
_
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
08/09/2015
$25.00
$25.00
First Name
Cassetti
MI
Anthony
City
88 Franklin St
Ansonia
Principal Occupation
Zip Code
CT
06401
Yes
No
_
X
Yes
No
Personal Check
Executive
Method of Contribution
X
State
Name of Employer
Construction
Cash
06401
First Name
O'Malley
_
_
Date Received
Last Name
Cash
Method of Contribution
Zip Code
CT
State
Name of Employer
Paralegal Specialist II
Cash
City
28 W Brookside Ave
MI
Patricia
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
08/09/2015
Aggregate Contributions
$500.00
$500.00
Page 5 of 26
TYPE OF REPORT
First Name
Marini
Residential Street Address
City
11 Hawley Dr .
Ansonia
Principal Occupation
Yes
No
_
X
Yes
No
Executive
_
_
06401
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
08/09/2015
$100.00
$100.00
First Name
Martin
MI
Gregory
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Graphic Artist
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Self Employed
_
Yes
No
Yes
No
Executive
Method of Contribution
X
City
13 Granite Ter
Cash
Method of Contribution
Zip Code
CT
HMPB Law
Cash
State
Name of Employer
Attorney
MI
Nancy
_
_
Credit/Debit Card
Payroll Deduction
Money Order
Last Name
Amount of Contribution
No
No
Legislative
Date Received
Personal Check
Yes
Yes
Aggregate Contributions
08/09/2015
$50.00
$50.00
First Name
Prestiano
MI
James
City
58 Morningside Dr .
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Retired
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Yes
No
_
X
Yes
No
Executive
Method of Contribution
_
Cash
Personal Check
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
08/09/2015
Aggregate Contributions
$25.00
$25.00
Page 6 of 26
TYPE OF REPORT
First Name
VITARIUS WAUGH
Residential Street Address
City
83 Prospect St
Ansonia
Principal Occupation
Yes
No
_
X
Yes
No
Executive
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Amount of Contribution
No
No
Legislative
Aggregate Contributions
08/09/2015
$200.00
$200.00
MI
City
162 Center St
Woodbridge
Principal Occupation
Yes
No
Yes
No
Executive
Method of Contribution
X
State
Zip Code
CT
06525
Name of Employer
_
_
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
08/09/2015
$25.00
$25.00
First Name
Villers
MI
Ralph
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Yes
No
_
X
Yes
No
Personal Check
Executive
Method of Contribution
X
City
33 Upland Ter
Cash
Yes
Yes
WARNER
06401
First Name
PYNE
Cash
_
_
Date Received
Last Name
Method of Contribution
X
Zip Code
CT
LH Brenner
Cash
State
Name of Employer
Insurance Agent
MI
JANET
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
08/09/2015
Aggregate Contributions
$25.00
$25.00
Page 7 of 26
TYPE OF REPORT
First Name
Nicolari
Residential Street Address
City
Ansonia
Principal Occupation
Yes
No
_
X
Yes
No
Executive
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Amount of Contribution
No
No
Legislative
Aggregate Contributions
08/09/2015
$300.00
$300.00
MI
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Yes
No
Yes
No
Executive
Method of Contribution
_
City
8 Sharyl Dr
_
_
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
08/09/2015
$40.00
$40.00
First Name
Carroll
MI
Randolph
City
40 Fourth St # 10
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Retired
Retired
Yes
No
_
X
Yes
No
Personal Check
Executive
Method of Contribution
Cash
Yes
Yes
Melissa
06401
First Name
Torres
Cash
_
_
Date Received
Last Name
Method of Contribution
X
Zip Code
CT
Self Employed
Cash
State
Name of Employer
MI
Judy
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
08/09/2015
Aggregate Contributions
$20.00
$20.00
Page 8 of 26
TYPE OF REPORT
First Name
Henri
Residential Street Address
City
16 Harris Rd .
Ansonia
Principal Occupation
Yes
No
_
X
Yes
No
Executive
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Amount of Contribution
No
No
Legislative
Aggregate Contributions
08/09/2015
$50.00
$50.00
MI
City
Ansonia
Principal Occupation
Yes
No
Yes
No
Executive
Method of Contribution
_
State
Zip Code
CT
06401
Name of Employer
_
_
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
08/09/2015
$50.00
$50.00
First Name
Rodriguez
City
108 Arthur St
Bridgeport
Principal Occupation
State
Zip Code
CT
06605
Name of Employer
Yes
No
_
X
Yes
No
Personal Check
Executive
Method of Contribution
_
MI
Jonathan
Cash
Yes
Yes
Anna
06401
First Name
Andretta
Cash
_
_
Date Received
Last Name
Method of Contribution
_
Zip Code
CT
Sikorsky Aircraft
Cash
State
Name of Employer
Electric Designer
MI
Patrick
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
08/09/2015
Aggregate Contributions
$25.00
$25.00
Page 9 of 26
TYPE OF REPORT
First Name
Conti
Residential Street Address
City
7 Buswell St
State
Ansonia
Principal Occupation
Yes
No
_
X
Yes
No
Executive
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
First Name
John
No
Legislative
Aggregate Contributions
$25.00
$25.00
MI
State
Zip Code
CT
06401
Name of Employer
Yes
No
Yes
No
Executive
Method of Contribution
_
_
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
08/12/2015
$189.00
$189.00
First Name
Tripp
MI
Philip
City
57 Eagle St
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Sales
Home Depot
Yes
No
_
X
Yes
No
Personal Check
Executive
Method of Contribution
Cash
Amount of Contribution
No
Ansonia
Principal Occupation
Yes
City
12 Shortell Dr
Yes
08/09/2015
Izzo
Cash
_
_
Date Received
Last Name
Method of Contribution
Cash
Zip Code
CT
Name of Employer
MI
Beth
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
08/13/2015
Aggregate Contributions
$100.00
$100.00
Page 10 of 26
TYPE OF REPORT
First Name
O'Malley
Residential Street Address
Oakville
Principal Occupation
Yes
No
_
X
Yes
No
Executive
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Aggregate Contributions
08/13/2015
$1,000.00
$975.00
MI
Joseph
City
72 Root Ave
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Retired
Retired
Yes
No
Yes
No
Executive
Method of Contribution
_
_
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
08/14/2015
$1,000.00
$1,000.00
First Name
BIASUCCI
City
57 Rockwood Ave
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
REGISTERED NURSE
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Yes
No
_
X
Yes
No
Personal Check
Executive
Method of Contribution
X
MI
NATALIE
Cash
06779
First Name
Cassetti
_
_
Date Received
Last Name
Cash
Method of Contribution
Zip Code
CT
City of Ansonia
State
Name of Employer
Grant Writer
Cash
City
MI
Sheila
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
09/03/2015
Aggregate Contributions
$400.00
$400.00
Page 11 of 26
TYPE OF REPORT
First Name
CZECZOT
Residential Street Address
City
37 Morningside Dr
Ansonia
Principal Occupation
Yes
No
_
X
Yes
No
Executive
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Amount of Contribution
No
No
Legislative
Aggregate Contributions
09/03/2015
$100.00
$100.00
MI
City
14 Highland Ave
Ansonia
Principal Occupation
Zip Code
CT
06401
Materials Testing
_
Yes
No
Yes
No
Executive
Method of Contribution
X
State
Name of Employer
_
_
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Date Received
Last Name
Aggregate Contributions
09/04/2015
$250.00
$250.00
First Name
Cassetti
MI
Gary
City
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Retired
Retired
Yes
No
_
X
Yes
No
Personal Check
Executive
Method of Contribution
Cash
Yes
Yes
Irving
06401
First Name
Reed
Cash
_
_
Date Received
Last Name
Method of Contribution
X
Zip Code
CT
YALE UNIVERSITY
Cash
State
Name of Employer
MI
JOANNE
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
Amount of Contribution
No
Legislative
Date Received
_
Yes
Yes
09/09/2015
Aggregate Contributions
$1,000.00
$1,000.00
Page 12 of 26
TYPE OF REPORT
First Name
Monaco
MI
Silvana
City
6 S Cliff St
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Retired
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Yes
No
_
X
Yes
No
Executive
Method of Contribution
_
Cash
Personal Check
Credit/Debit Card
Payroll Deduction
Money Order
Yes
Yes
Amount of Contribution
No
No
Legislative
Aggregate Contributions
09/17/2015
$100.00
$100.00
First Name
WHEELER
City
53 Benz St
Ansonia
Principal Occupation
State
Zip Code
CT
06401
Name of Employer
Yes
No
Yes
No
Personal Check
Executive
Method of Contribution
X
MI
GORDON
Cash
_
_
Date Received
Last Name
_
_
Credit/Debit Card
Payroll Deduction
Money Order
No
No
09/18/2015
Aggregate Contributions
$30.00
Total of Section B
(Sections A & B)
Amount of Contribution
Legislative
Date Received
_
Yes
Yes
$30.00
$6,454.00
$6,454.00
Page 13 of 26
TYPE OF REPORT
Name of Committee
Chris W. Tymniak
Address
Yes
No
Amount of Contribution
City
Fairfield
State
Zip Code
Date Received
CT
06824
08/12/2015
Aggregate Contributions
$250.00
Total of Section C1
$250.00
$250.00
NAME OF COMMITTEE
Name of Treasurer
Address
Date Received
State
City
Zip Code
Amount of Receipt
Payment Type
Reimbursement for shared expense
Surplus Distribution
Description
Total of Section C2
Page 14 of 26
TYPE OF REPORT
Source of Loan:
Bank
Street Address
Date of Receipt
Candidate
City
Individual
Other
State
Zip Code
Is there a cosigner or
Guarantor of this loan?
Yes
No
Amount Received
Street Address
City
State
Zip Code
Total of Section D
TYPE OF REPORT
E. Receipts from Entities other than Individuals or Other Committees (Referendum Committees ONLY)
Name of Entity
Street Address
Date Received
State
City
Zip Code
Amount Received
Aggregate Contributions
Total of Section E
TYPE OF REPORT
October 10 Filing - Original
F. Amount Transferred from Affiliated Business Treasury (Business Entity Committees ONLY)
Date of Receipt
Yes
No
Amount
Total of Section F
Page 15 of 26
TYPE OF REPORT
October 10 Filing - Original
G. Amount Transferred from Affiliated Labor Union or Other Organization Treasury (Organization Committees ONLY)
Date of Receipt
Amount
Total of Section G
NAME OF COMMITTEE
Method of Payment
Amount
Cash
Personal Check
Credit/Debit Card
Total of Section H
TYPE OF REPORT
October 10 Filing - Original
Date Received
Name of Institution
Street Address
City
State
Amount
Zip Code
Total of Section J
Page 16 of 26
NAME OF COMMITTEE
Date of Transaction
Pumpkin Festival
09/20/2015
Street Address
City
State
Zip Code
Seymour
CT
06483
Amount
Received
Description
$2,496.00
$2,496.00
Total of Section K
TYPE OF REPORT
Letter
Description
City
Yes
No
Yes
State
No
Zip Code
No
Was this fundraiser a tag sale, auction, or other sale of donated items with
puchases from an individual of up to $100?
Yes
No
Subpart 2: (Party Committees, Municipal Candidates and Political Committees other than Exploratory Committees)
Were there purchases of advertising space in a program book or on a sign associated
with this fundraiser?
Yes
No
Yes
No
Total of Section L1
Page 17 of 26
Other
Individual/Sole Proprietorship
Street Address
Date Received
City
Event #
Zip Code
State
Total of Section L3
City
Street Address
State
Description of Donation
Business Entity
Individual
Date Received
Zip Code
Event #
Sole Proprietorship
Total of Section L4
Page 18 of 26
TYPE OF REPORT
October 10 Filing - Original
L5. In-Kind Donations Not Considered Contributions Associated with a House Party
Is this event supporting more than one candidate or committee?
Yes
No
City
Street Address
State
Description of Donation
Zip Code
Event #
Total of Section L5
City
Street Address
Type of Contributor:
Committee
Date Received
Aggregate contributions
State
Zip Code
Other
Yes
No
Yes
No
Yes
No
Executive
Legislative
Total of Section M
Page 19 of 26
TYPE OF REPORT
First Name
City
MI
State
Zip Code
Street Address
City
State
Zip Code
Total of Section N
Amount of
Deposit
Page 20 of 26
TYPE OF REPORT
October 10 Filing - Original
Date of Payment
EverReady Press
09/03/2015
Street Address
City
Clifton Ave
Ansonia
Purpose of Expenditure
(by code)
Expenditure #
(if applicable)
Check #
Debit Card
174
State
EFT
Zip Code
CT
Description
A-SIGN
Method of Payment
06401
Amount
Event #
Lawn signs
Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)
$6,604.34
Independent
Organization
Name of Payee
Date of Payment
09/11/2015
Street Address
City
98 Bank St
Seymour
Purpose of Expenditure
(by code)
Expenditure #
(if applicable)
D
Method of Payment
X
Check #
Debit Card
175
State
EFT
06483
Event #
Food Permit
Zip Code
CT
Description
FNDR *
Amount
09202015H
Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)
$65.00
Independent
Organization
Name of Payee
Date of Payment
Lorie Vaccaro
09/23/2015
Street Address
City
515 Beaver St
Ansonia
Purpose of Expenditure
(by code)
D
Method of Payment
X
Check #
Debit Card
State
CT
Event #
Description
FNDR *
Food
176
_
EFT
Zip Code
06401
Amount
09202015H
Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)
Expenditure #
(if applicable)
X
$783.25
Independent
Organization
Page 21 of 26
TYPE OF REPORT
October 10 Filing - Original
Date of Payment
The Hartford
09/23/2015
Street Address
City
1 Hartford Plz
Hartford
Purpose of Expenditure
(by code)
Expenditure #
(if applicable)
Check #
Debit Card
178
State
EFT
Zip Code
CT
Description
Misc *
Method of Payment
06155
Amount
Event #
Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)
$425.00
Independent
Organization
Name of Payee
Date of Payment
Kirk Products
09/24/2015
Street Address
City
1 Rimmon St
Seymour
Purpose of Expenditure
(by code)
Expenditure #
(if applicable)
D
Method of Payment
X
Check #
Debit Card
181
State
EFT
06483
Event #
Zip Code
CT
Description
FNDR *
Amount
09202015H
Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)
$30.00
Independent
Organization
Name of Payee
Date of Payment
09/24/2015
Street Address
City
Clifton Av
Ansonia
Purpose of Expenditure
(by code)
D
Method of Payment
X
Check #
Debit Card
State
CT
Event #
Description
A-SIGN
179
_
EFT
Zip Code
06401
Amount
Palm cards
Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)
Expenditure #
(if applicable)
X
$2,956.51
Independent
Organization
Page 22 of 26
TYPE OF REPORT
October 10 Filing - Original
Date of Payment
09/24/2015
Street Address
City
Clifton Av
Ansonia
Purpose of Expenditure
(by code)
Expenditure #
(if applicable)
Check #
Debit Card
180
_
State
EFT
Zip Code
CT
Description
A-SIGN
Method of Payment
06401
Amount
Event #
Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)
$116.99
Independent
Organization
$10,981.09
Total of Section P
Date of Payment
Is Reimbursement Claimed?
Yes
Purpose of Expenditure
(by code)
State
City
Street Address
Description
Event #
No
Zip Code
Amount
Total of Section Q
Page 23 of 26
IV. EXPENDITURES
TYPE OF REPORT
Visa
Master Card
American Express
Discover
Other
Date of Transaction
City
Street Address
Purpose of Expenditure
(by code)
Expenditure #
(if applicable)
State
Description
Zip Code
Event #
Amount
Type of Expenditure ( Itemization in Addendum R Required unless "None of the below" is checked)
Independent
Organization
Total of Section R
IV. EXPENDITURES
NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)
TYPE OF REPORT
Name of Creditor
City
Street Address
Purpose of Expenditure
(by code)
Expenditure#
(if applicable)
Description
State
Amount Incurred
(Estimate or Actual)
Event #
Type of Expenditure (Itemization in Addendum S Required unless "None of the below" is checked)
Independent
Organization :
Zip Code
Total of Section S
Page 24 of 26
TYPE OF REPORT
First
MI
Check #
Street Address of Vendor, Person or Entity Paid by Committee Worker/Consultant
Purpose of Expenditure
(by code)
Expenditure #
Debit Card
City
State
Event #
Description
Organization:
Total of Section T
TYPE OF REPORT
L5. In - Kind Donations Not Considered Contribution Associated with a House Party - Addendum
Event #
Name of Candidate or Committee
Zip Code
Amount
Type of Expenditure ( Itemization in Addendem T Required unless "None of the below" is checked)
EFT
Page 25 of 26
Section P. ADDENDUM
TYPE OF REPORT
NAME OF COMMITTEE
Supported
Amount of Expenditure
Opposed
Section R. ADDENDUM
NAME OF COMMITTEE
TYPE OF REPORT
Supported
Amount of Expenditure
Opposed
Section S. ADDENDUM
TYPE OF REPORT
NAME OF COMMITTEE
S. Expenses Incurred by Committee but Not Paid During this Period - Addendum
Expenditure #
Supported
Opposed
Amount of Expenditure
Page 26 of 26
Section T. ADDENDUM
TYPE OF REPORT
NAME OF COMMITTEE
Supported
Opposed
Amount of Expenditure