Affidavit for Erick Bennett by Record Journal

=FORM 20

,c.emized Campaign Finance Disclosure Statement ::;ONNECTJCUT STATE ELECTIONS ENFORCEMENT COMMISSION :1.ev.. 1/{}7

SUMMARY PAGE

o January 10 filing o April 10 filing o July 10 filing o October 10 filing

.4t

7th day preceding primary

7th day preceding referendum

o Initial Contribution or Disbursement (pACsONLy)

030 days following primary

o 7th day preceding election o 12th day preceding election

o 45 days following referendum o Deficit o Terrnination

o Amendment to

(State Central Committees Only)

Type of Report:

Date Filed:

045 days following election

Beginning Date

r(;7b9

thru

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.

/!eik Il

6! 1&C;)L;:r~

PRINT NAME OF SIGNER

PENALTY FOR FALSE STATEMENT IS PUNISHABLE BY FINE NOT TO EXCEED $1,000, OR IMPRISONMENT FOR NOT MORE THAN ONE fEAR, OR BOTH.

~F.c' ~

'ORM 20

~ampaign

Finance Disclosure Statement

J--.;TlCUT STATE ELECTIONS ENFORCEMENT COMMISSION .1/01 Page 2 of16

SUMMARY PAG E TOTALS

1 I. Balance on hand January I of current year for Ongoing and Party Committees OR Balance on hand from Committee was formed for all other committees

3. Contributions

,oc

from

5. Other Monetary Receipts (Sections D-K) 6a. Total Small Food and Beverage Receipts at Fair (Section Ll) Town Committees ONLY 6b. Total Proceeds from Small Purchases at

Auctions or Other Sales

路7. Total Monetary Receipts (add totals for lines I3-16c) totals in line 12 + line 17 in Column A; and in line 11 + 17 in Column

I. Subtotals 9.

Paid (Section

,), Balance on hand at close of Reporting Period

1. In~Kind Donations not Considered Contributions Received (Section fA) 路L In-Kind Contributions Received .3. Refundable Advances of Deposit to Telephone Company (Section N)

:: 4a.

?4b.

Interest and Penalties on Loan on Loan

24c. Total

Loans

25. Campaign

Paid

Candidate Committees ONLY

Incurred on Committee Credit Card (Section Q) ~7.

Incurred

this Period but Not Paid

o ()

(o(llribution is in excess of $400 tQ a candidate committee for a chief executive officer of a municipality does contributor or business bclshe is associated with have a contract witl! said valu~d <It more than DYes D No b this contribuuoll assoclat:;;d \vith .a fundralsing ev"ut lisleL' in Section L I? Ifyes, list EVClllli

JA.

Yes

Method of contribution! ~Cash D Personal Check D Payroll Deduction

D CreditIDebit Card

~~~~~--~~~~~~~---~=-~~~--~r-~~--------------------~----~

Amount of Contribution

If contlibution is in exc~ss of$400 to a caudidate COllUl1ittee for a chiefexecutwc officer of nlClllicipaiity does contributor or bus;cess he/she is associated with have a contract with said valued at more thaLl DYes D No ~Yes No

lmall,cr~,alll'l

Method of contribution: ~ash D Personal Check

CredrtIDebit Card

D Paymll Deduction

does contri~ll!or or business helsllc is valued at more ilian $5,000? DYes ~No

as,iOClau~a

Method of contributioll! D Cash J,i"'Personal Check D Payroll Deduction '

D Credil!Dcbit Card Contribution

[I' contribution is in to a candidate committee for a chief executive of a 1l1l.1(1j,;ipa!ity does contributor or business be/she is associated with bave a contract with said lllunicipality valued at more thun $5,0007 DYes 0 No

is leis contributlou aS$oci;a[eJ with a tlmdrai::.iug event 1i:;tcd in Secliol1 LI? ffy"s, list Event Ii

DYes ~No

Method of contribution' D Cash ,f'YPersooal Check D Payroll Deduction

D Credit/Debit Card

Contribution

contribution is in excess of $400 to a candidate committee for a chief executive officer ofa t1111llktpality docs contributor or business heishe is associated with have a contract with said valued at more ilia:.! $5,0007 is mis contributlOfl associated with a [lJUJrui.:llng evem listed in Section L 1'1 1/yes, list E\'ent II

DYes

D No

Method of contribl.tion! D Cash I!J Personal Check D Payroll Deduction

contribution is ill excess of $400 (D a calldidate """,;";,,"1;,,, dDes contributor or business he/she is associated with bave a contract with said mll'""InAII'V valued at more than $5,000? DYes D No Method of contribution! D Cash .B"Personal Check D Payroll Deduction

If contribution is in excess of $400 to a candidate committee for a chief executive officer of a municipality does contributor or business he/she is associated with have a contract with said valued at more than $5,OOO? DYes D No D Yes fA No

Method of contribution: D Cash ~ Personal Check D CreditlDebit Card D Payroll Deduction Amount of

Contribution

contribution is in excess of $400 to a candidate committee for a chief executive officer of municipality does contributor or business he/she is associated with have a contract with said municipality valued at more than $5,OOO? DYes D No bution associated with a

DYes No

fil

Method of cc)ujribution: D Cash it'Personal Check D CreditIDebit Card Payroll Deduction

Contribution

Method of contribution: Cash ~ersonal Check Payroll Deduction

CreditIDebit Card Amount of

~~tf~~~~~--~~~~~~~~~~~~~~~~~~~~------~~~~~~~-----------------------------------1

Contribution

to a candidate committee for a chief executive officer ofa he/she is associated with have a contract with said DYes D No D CreditIDebit Card

Amount of

:~~~~~~~~~--~~~~~~~~~-----r,~~~~~------~~~~~~~--------------------------------1 lobbyist, spouse, :~pendent

child of a lobbyist?

IS m excess $400 to a candidate committee for a chief executive officer of a mU:nJ(:lpalil';y does contributor or business helshe is associated with have a contract with said valued at more than $5,0007 DYes

Is this contribution associated with a fundraising event listed in Section L I? list Event #

~ Yes No

Method of c~bution: D Cash :td1'ersonal Check Payroll Deduction

Contribution

C(}l~tributio!l

...

~' "

Amount of Contribution

If COlltlibUllOll is in ~xcess of $400 to a candidate cOllunittec for a chief C""C1UUVC does contribulor or business he/she is associated with have a contract with said lllt:llJILll.V valued ul mo,e than $5,0007 DYes

Is litis contribution associated wlth:1 DYes fumiraising tveut h;;ted iu Section Ll? ~o f/yes, lis! Event If

Method of contribution: D Cash Personal Check D Payroll Deduction

1lJ

D CleditlI)ebit Card

/()().oo Amount of Contribution \1

If contribution is in excess

municipality does conlnbutor 0' business he/she is associated witi! have a coutraet wtth said ntU!.11cipality valued at more than $5,000? DYes

hi lht!:i coutribation associated with a

t1wdrlJlsiug event hsku in SecLion L I? , ffy<'s, lisl Event II

DYes

p..--No

r"kthod of contribution: D Casll .foih'ersonal Check D Payroll Deduction

Contribution

.Jlt

municipality does contributor or busiuess he/she·

municipality valued at B:ore than $5,0007

Is this ¢ontributlOll aS$ocia[~J with a fuuJruisicg everl( lis[cd In Secliull Ll'l IfJ'"s, list Event #

DYes

jl-No

Metbcd of contriblltion; Cash ~Persona\ Check D Payroll Deduction

D CreditiDebit Card

a Amount of Contribution

~ No

to a candidate comminee a chief executive officer of a municipality does contributor or busiuess he/she is associated with have a contract with sai(i municipality valued at more than $5,0007 DYes D No

b illis contribution assodatcd with a fuudraising ~vent listed ill Section L I') IfYeS, list Event #

~ Yes

Method of contribution: A;-Cash D Personal Check D Payroll Deduction

D CreditfDebit Card Amoulltof Contribution

of contributiol1~

6i!'1:asb D Person~J Check D Payroll Deduction

CreditIDebit Card

C&'l.t.dbution

co路 Amount of Contribution

rfif'Ves D No

Mettod of contribution' D Cash Vl Personal Cbeck D Payroll'rledudion

D CteditlDebit Card AnlOunt of

~~;c;:-;i;=~T,:9'-!'=:'--I4~~~~';;;!.--I-~---------ro:-.,--=-,,:-;-----h:-=-:-:""'=T"'=---------____________- j COll~ributi(llI

to a candidate committee for a chief exec~tive officer of a does contributor or business he/she is associated with have a contract with said DYes No valued at more than $5,000?

if cOlltributiQu is in excess

Method of contribution: D Cash 1jl Personal Check D CredillDebit Card D Payroll '6eduction PrlncipalOcrupatLlJ:.1

Amount of

Contribution

Amount ()f Contribution

to a candidate committee for a chief executive officer of a If eontribut[un is ilt excess of municipality does contributor or business he/she is associated with have a contract with said lIl11uicipa!ity vahled at more than $5,0007 DYes D No

...qzt-yes D

Method of c~tribution: 0 Casb !,Il Personal Check D PayroH Deduction

D CredilJDebit Card Amount of Contribution

If contribution is in ex;:css of $400 to a candidate committee for a chief executive offIcer of a municipality does coutributor or business he/she is associated wilh have a contract with said muuicipality valued at more thau $5,000? DYes D No Is trus contribution associated with a fundraising event listed in Section Ll? Ifyes, list Event #

{itD

Yes No

Mdhod ofc~bution: D Cash ~ Personal Check D Credi~TIebit Card D Payroll Deduction

~ No

! r contribution is in eXCeSS of $400 to a candidate a l\llllllCioulilv does contributor or business belshe is associated with have a contract with said municipality valued at more than $5,000? DYes D No

Yes No

IMethod of contribution:

'D Cash ~rsona! Check 0

o Payroll Deduction

Credit/Debit Card

sv. (')0

-9, (7 (T Amount of Contribution

PrincipQt Oc(;upation

o CreciitlDelJit Card

,od Contribution ',;

J! C01l1rlbc:Uon is in excess of to a candidate committee for a chief executive of a :1lUtllClpality does contributor or business he/she is associated with have a contract with said 1l1utlicillaiily valued at !!lore Wan $5,000? DYes D No

es No

Method of contributioll:

$ Personal Check D Co'ediUDebit Card o Payroll Deduction

Q Cash

Amount of Contribution

If cl.lntrib,r(:l.ltl is ill excess of $400 to a candidate committee for a chi:;f executive oftlcer of a llhltl;cljJ,,!iry does contributor or business he/she is associated with have a contract with said DYes 0 No llluUldpa1itj' valued at more tlralJ $5,000'1

Is this coritributioH aS$t1Cii1tel~ with ~: fuuJraisiog eveat listed ill Sectlc.Hl Ll ? IfJ't!s, list EVCUl#

Ycs 'ctlfi'J No

Method of contribution: o Cash \:K1'ersonal Check Payro'tl Deduction

o Credit/Debit Card Amount of Contribution

If c,Jnlribution is Ul excess of to a cmdidate committee for a chief executive officer of a mUDicipillity does coutributor or busiuess he/she is associated with have a contract with said DYes 0 No llluuicipaiity valued at more wan $5,0007 /rIlYes

Method of contribution: Cash ~ersoaal Check D Payroll Deduction

D Crc:ditlDebit Card

If cOlHlibution is in excess of $400 to a candidate committee for a chief executive officer of a municipality does contributor or business he/she is associated with have a contract with said vahled at morc than $5,000? DYes D No Is this conlributlon associated wi funciraising event listed in Sectioll list Event II

Yes

Method of contribution: Cash ~sonal Check Payroll Deduction

o o

ofa

Method of contribution: D Cash ~rsonal Check D CreditIDebit Card D Payroll Deduction Amount of

Contribution

If cOlHribul:oll is in exceSs of $400 to a candidate cOl1unittec for a chief executive officer of lUlitucipality does contributor or business he/she is associated with have contract with said mUl\icipality vaiued at [nore [han $5,000? DYes D No

Yes

D No

Method of contribution: D Cash ~ersolial Check D Payroll Deduction

D CrediUDebit Card

Contribution

If conlrib"tiou is in excess of to a a chief executive officer of a does contributOr or busilless he/she is associated with have a COlltraet with said valued at mor" than $5,0007 DYes D No

1Q! Yes D No

Method of contribution: D Cash ~ersonal Cbeck D Payroll Deduction

D CreditIDebit Card AmOunt of Contribution

If col1lnbulion is in excess of$400 to a candiciate committee for a chief executive officer of a !m:nicipality does contributor or business he/she is associated with have a contract with said mOlHel tty valued at more thao $5,000? DYes D No 1$ [his contribution iJSSocJ;jleJ WiL~l a ~es fl1udraislng evenl listed in Seetioll L I? D No JIyes, list E\'cm 1/

tv:ethud of c~tributiol1: D Cash t!f Personal Check D Payroll Deduction

CreditJDebit Card

Contribution

If contribution is in excess $400 to a candidate committee for a chief executive officer of a municipality docs contribntor or busilless helshe is associated with have a contract with said valued at more thall $5,0007 DYes No

Is this ~onlTiblltion associated with a ii.lmiraising event listed (\1 Section !_1 ? I/yes, list Event /I

!;f--Yes D No

Method of contribution: D Cash 0 Personal Clleck D Payroll Deduction

CreditIDebit Card Amount of Contribution

If contribution is in excess No

to a candidate committee for a chief executive officer of a municipality does contributor or business he/she is associated with have a contract with said valued at more than $5,000'1 DYes D No

Is this contriburion associated willi u 1:i.1ndraising event listed in Section L I? list Event II

Method of contribution: D Casb 0 Personal Check D Payroll Deduction

C(}lI.tribution ":,'

If cDntribution is in excesS of $400 to a ca!)didate committee for a ch municipality does contributor or busmess belshe is associated with have a contract with said lity valued at nhJre than $5,000? DYes D No Method of c~rribution: D Cash !i!t1'ersonal Check D Payroll Deduction

is tillS contribulioll ~J5soci;Jtt:d wich u fumlraising cveut listed ill Section LI '? Ifyes, list Event Ii

CreditIDebit Card

I~. Amount of Contribution

if contribution is if: excess cOl1:tllittee for a chief Jl1utlicipaiity does contribtilor or business helsbe is associated with have a contract willi said municlpality valued at more tnac DYes No Is this l路o,mibutioa associated with a tUlldraising eveut listed IU Section Ll1 Ifyes, Ilst [Vem if

DYes ~No

Method of contribution: D Cash ~ersoual Check

Credit/Debit Card

D Payroll Deduction

.~~~~~-L'-.--L~~':::""~~----rc:;:;;:;:---r:~~~:;;;;c;n:~~~----------j cOlllribulur a lubby:s!, spouse, dependent child oLl lobbyist?

Amount of Contrihution

If contribution is in excess of $400 to a committee for a chief executive officer of a 11lll1:iclpality does conlribllto~ or busilless helshe is associated willl have a coutract with said lllllnicipaiity valued at morc Waf! $5,0007 DYes D No

l~ fbis CUlHributiou :lssociatcd with OJ fimuruisi[Jg cvtnt listed in Sec lion L 1'!

...;;;!D

Yes No

I/yt's, list Event Ii

Method of contributioll" D Cash ~sonal Check D Payro'l Deductilln

CrediUDebit Card

If contribution is in excess of $400 to a candidate a municipality does c01ilnbutor or bl,c;uess heishe is associated wilh have a contract with said municipality valued at olOre than $_,JOO? DYes D No

Is tlm contribution aSSociatelt with ,) fUlldraisillg event lis(t.:d in Section L 1? lIyes, list Evcnl f!

DYes

McWud of contribution: D Casb .J2lri>ersonal Check D Credit/Debit Card D Payroll Deduction Contribution

If contributiOll is in excess 0[$400 to a candidate committee for a chief executive officer of a municipality docs contributor or business he/she is associated with have a contract with said DYes D No llHiuicipality valued at more wan $5,0007

DYes

..-a-

Method of contribution: D Casb ~ersoual Cbeck

D Payroll Deduction

CreditIDebit Card

L>nllllIlJlllll<Cill

is in

C'lCCSS

or $400 to a candidate committee for a

municipality does cOl,triut:tor or business he/she is Bsso~jated with have a contract with said

valued at mure than $5,000?

!1'Yes

NlJ

DYes

Metaod of contribution: D Cash it!t1>ersonal Check D CreditIDebit Card D Payroll Deduction Amount of Contribution \~

l'tletirod of contribution: ~ash D Personal Check D Payroll Deduction

D CrediUDebit Card Amount of Contribution

to a candidate committee for a municipality does contributor or bosiu~ss he/she is associated with have a contract with said illunicipality valued at more than $5,000'1 DYes D No

-fif Yes

Is t1Jis cuntributioll a:;sociateJ with' I?

Method of coub'ibution: ~h D Personal Check D Credit/Debit Card DPayroil Deduction Principal Occupation

'-:J~;!'f~~~~;s;'-'-"",:2-;-~L~-1't7rY---;---1Siat.;-I;ITDCc~路---jiffimeorTIii;ptOYe'f-------------------1

Amount of Contributioll

If contribution is in excess of $400 to a candidate committee for a chief executive officer of a municipality does coctrib\ltor or business helshe is associated with have a contract with said municipality valued at more than $5,0007 DYes D No

Is this contribution associated with a fuudraising event listed in Section L I? Ifyes, list Event II

2-Yes

Contribution

If contlibulion is in excess of $400 to a candidate committee for a executive officer of a municipality does coutribu[or or business he/she is associated with have a contract with said municipality valued at more thac $5,0001 DYes D No Is this contribution associated with a

Method of contribution: lih::ash D Personal Check D Payroll Deductioo

','

C(}ll.t"ributioD \1

Method of contribution: D Cash q:tl.Persollal Check D CreditJDetnt Card D Payroll Deduchoo Amount of Contribution

JP- No

I IS

in excess of $400 to a candidate committee for a chief executive officer of

murJcipalily does contributor or business he/she is associated with have a contract with said

lllunicipalilY valued at llime tha!]

is litis cODtribu(lon a$$O(i~Hed with a IUlJUralslIlg evcnl I iSled ill Section L j') J/YdS, list Event ti

DYes

D No

Method of c~J!;jbutioll: D Cash i:lf1"ersonal Check D C,eGit/Debit Card D Payroll Deduction Amount of Contribution '"

"onlriblltiOll is in excess of $400 to a conU11ittee for a llluniclpality does conlributor or busluess helshe is associated with have a contract with said lllt! valueG at more than $5,000'1 DYes D No

DYes

~No

Method of contribution: D Cash Â˘ PersOllal Check D CrediliDebit Card D Payroll Deduction P;incipat Oct:upatilJrI

Contribution

I r conrribuliOll is in exeess a to a caudidate cOllunil1Cc for 2 chief executive ofllcer of a l1l11l1icip:1lity docs contribulor or business he/sbe is associated with have a corltraC! with said ll1ulliuipalit valued at more thUll $5,0007 DYes 0 No 1:-: this conlributioll i.\$suciu[cu witLJ n fuudraising eveot listed ill Section L I '! IJyes, list Event II

DYes

.l;J-No

Method of cOl1tnbution: D Cash )!h>ersl,cal Check D Credit/Debit Card D Payroll Deduction

Contribution

rf contribution is in excess 0[$400 to a candidate corrunittee for a chief executive officer of a municipality does contributor or business he/she is associated with have a contract with said DYes D No flluuicipaiity valued at more thall $5,000?

Yes

~ No

Method of contribution: D Cash tIa15ersonal Check D CreditJDebit Card D Payroll Deduction Contribution

cOtltnbution is in excess $400 to a committee for a executive officer of a mUl;icipality does contributor or business he/she is associated with have a contract with said DYes D No l1mwcipality valued at more than $5,0007 Is this contribution associated with a fundmising eYeD[ listed in Section L I'! lise Eveoc #

~~~~~~~~~

Q---'Yes 0 No

Method of c~bution: D Cash Personal Check D CreditlDebit Card 0 Payroll Deductioll

tt:r

C(ftl.rributioll \; '.:'

of cot.lrril:uti\.)n: 0 Person,,1 Cbcck Payroll Deduction

~ash

Credit/Debit Card Amount Gf Contribution

\P1UICipaIOccl:;Ji.I!iOn i

o CrcliltfDcbit Card Contributioll

CAOC'.'U

[jHL,il.路i~:..t!i(y IJoes cOlltribulor or busiues$ hc/sht is assocw(cd

vHlliCll ntmore ttuJJ\ $5,0007

elf \' es

OY cS

'co 0 [fiecr

of a

with have a COl1tra(t yvith s.lid No

Methou of cOlllributiun: ~sli

LJ Payro II

Persunal Check Deductioll

Credil/Debit Card

Aniount

Contributioll

It l "!\I! ,blit;oH i$ III excess $40G [0 U cdlltliuale cummittee Il)[ a chief execulive oftictr 01" !w'dicl(dity dOes cllnt!JbULUI or bllsiuess Itt/she j, l1ssocidtcu with have a comract with gelid

Oy cs

v,ilued at Hlore [Ilan $5,000? ~ycs

1\ku,uu uf contribution: ~ash 0 Pe.rsouai Check Opu'

CrcddlDebit Card

Cred!tlDebit Card

tV[ctllOcl ot' contribution: .,IQ.easll

Personal Check

o Payroll Deductio[l

Principai Occt:patiou

Amuuot of

COlltribl!tiol'

Mcthoci at' contribation: ~sh D Personal Check D Payroll Deduction Pril1c~pal

D Credit/Debit Card

Occ:Jpa:ion

If coatribulioll in excess of $400 to a candidate committee for a cber executive officer of municipality does contributor or busmess he/she is asso~ialed with have a contract with said 11ll1l:icipalily valued at Clore than $5,000? DYes D No tJ-Yes No

Method of contribution:

~ash

Personal Check

D CreditJDebit Card Amoulltof

~=f:-!:-'':+-i~'~::::-'...-.-l£L~r¥-'=:'':''':=---"T;:-"-=c--;c-,~--+n---'''''~

comcibutor a lobhyist, spouse, dependent chitd ul'" lobbyist?

_ _ _ _ _ _ _ _ _ _ _ _ _ _-l C()utriuutioll ',,'

If cOlllribulloll is in exceSS of $400 to a candidate committee for a chief executive of a Illlllli,ipality does contributor or business he/she is associated with have a contract with said lllunic· I valued at more thall $5,0007 DYes D No

is rhis cuntriblllioe assoc:i~lkL! with ~1 hllldrdising evenl listed in Section L 1'? If yes, list Evcnlli

~ Yes D No

f\1etilod of contribution:

atasb D Personal Check D CleditJDebit Card tJ PayroH Deduction Aruwnt of Contrii1utioll

if contrib,HiOll is m eXl:CSS to a candidate committee for a chief executive officer of a lllull<ci;JHliry does cOlllribuloror business he/she is associated with have a contract with said lllunicipality valued at mure tbau $5,0001 DYes D No is tbi., cOlllribulll)U associated witb a fUUJldlSi[lg event liSicJ in Section L I? Ifyes, list EI'Clll II

Yes No

Method or contribution: ~h

0 Personal Check 0 CrediifDebit Card 0 Payroll Deduction

c:l)£:"..£1d

PrincipalOccupatioll

Amollntof Contribution

If contribution is in exccss of $400 to a cartdidate cOl'nrnittee for a chief executive officer of a muuicipality does contributor or busiuess he/she is associated with have a contract with said llluuicipality valued at more than $5,0007 DYes D No

Is this contribution associated wlih a nll::draising event listed in Section L I'! IIye~, iist Event II

Yes

'f,i:'r' No

Method of contribution:

D Personal Check D Payroll Deduction

'if2jCasb

Amount of

Contril:i'o~~ou

Amount 01

Contribution

!lll!H1(lpa!;Ly docs cUI:lnbub,)J' or bUSlIH:'SS tie/soc is assoL~lat~d wilil have a coutnld with said IlHliHcipality vaiued ai 11l0r" l~;Jll :)5,0007 DYes 0 No h

llli-s ":UIll! \hU!IIJ!l :I:J:.l1L'i:lh..'l1

L路UIH.!!

::.ti~lll~ (Vent !I~kl:

If yes,

k.l h'Cl1l

with

III S\,.'I.:tlrJn

L I)

i2F

Yes

[J Nt)

McluOct of l'oulnbUliol1' ~sh C Persaual ChCl'k 0 C!cditlDcb,t Card o Payroll Dccictc(io:\

""c:,ic''I"t/iry due:; c0IHnblilor O! bll~iuess hc!she IS associated witl, jll:luil'!~)Jlily V<JIUl~.d i.~( more tban $S,OOG? DYes 0 N b

tillS \路\)tltnblill~ltl :\s~uciatL"d wili;

h'i!JldbiL~

l'\'CUl

a hSkd III S'-'C[IUt: Ll '!

Yes

~No

I\路ktbod of cL1utribul!OIl'

o Cash ~isollai Cllcck o Payroll Deduction

Cn;dil/Debit Card Amoullt or Cuntributioll

Method of cont:ibution: Cash ,Je-personul Check o P"ymll Deduction

Amuun[ of Contrlllll,tiol!

II' cllutribullon is ill eXL'cSS of $-'\00 to a c,mdidate committee ll!!".icipaliry does c()urribuwr 01' business heishc b associuttd wilh hay~ a contract Wilh said DYes No lllulljc'ipainy valued at 11lOre tl,au is [his coulribuli":'!l ~i5S0(i:..ll('d wah a il!lldL!ising t.'\'Cllt li;;(;.;d in St(tillll L 1'; ify,,>, IlS' [vent il

j\'\eihod of contL1bLltion: Casl1 ~rsoual CI:eck Payroll Deduction

o o

Creditfj)ebit Card

t( l ulltdLllHiol: l~ in excess

,-If $400 lo i;i ciludiJiltc conlilUn~e fur a doC's L'olllril)Ulor Of ~ltSi(I<:~S ildsi11..': is associated wj~h havz: n !lHlllit.:ipttiily VHtd!!": aL !\lOrc thai! $5,OOO? DYes 0 No

\~l\lllil.:iparity

';;:-"-"----~---~~--r~_:\~, ".:~lIjlnl\Ul\lllj

dS:-:U,-'1;Jlni \','1:11

i !'.:l~'.l!ai::".lill~ <":\Tllt llsint ill S<,;'\..'UUtl

L i?

~rr!!."", hst l:\'t"llt It

DYes Nu

, tvktb~)u of COtlll'ibu:iciii

, D Cash

~crs("lal Cioeck 0 CrcdirfDebil Card

o Payroll Deduclion

Amount of Contribution

If ":1lt1trilhlti~'HI1S in cxt.:~ss 01'$400 to a canuidate- i..\Hllrnlt~t:e fDr a cuief cxt!cuttvc officer of 1",)uniL'ipality dues ',:ullll;bdlor Or business Llc/she is (!S$Oci:lted with havL: u coutnict with s(}\d vah'"t! eet "Iurr [l,au $5,000'1 DVes D No M_ctuod vfl'oetnbuti,JIl: ('<:s\; VP"rsoua! Cbcck 0 ClcdiUDebi[ Card D Payroll Deduciicl!\

AmQunt uf COlltribution '..:

Ir \''-\\Ilrjbu~io1i is in c.\(cSS of $400 CO a cHuLlldate COaU11!ae'~ for,~ chief ('xe:Cl!tiY~ officer ofa lliulli'-'ipalilj' dues cQlllribtllor or busluess he/she IS a:)socialeu \vith l1ave a coutrac{ with said 1i;"I;~cip"llly valde,1 <I[ m,'r" [l1all $5,000'1 DYes 0 No 路~路----~--~---I------_______L. b; lIii;; t'uutriblHIOll ;1:)c;0.:i'1\cd wilh ~\ hl!ldrdisill~, \.".'t'\\l Ilstcd III SCL'llU!l L j'l I 1/.1'':::;. list L::'.'Clll il

l'vlerhod of coutnbu~ion:

L! Cd,

~C,somll Clleck

o PJ.yrDH Dcducliol:

Crcdii/Debit eml Amount or Contributiull

,(\ll!{illHlllll lj

,llubhyisL, ~pnUSc'l

ofa

dC\1clldnll cbltl ul .. ', iubb\'i~(:'

o Crecht/Debit Card ',IIHt:

Amount uf Comributlull

SPUU:-;t'",

dc:p':ntient ~hi!d

(if;1

~nboyi:)L?

YeS No

11' coatributiOH is ill excess of $400 to u candidate COlllnuttec for a chief ex.ecutive officer of a Joe, coutrillll[()[ or business he/slJe is (lSsQcialed with bave " contract with said vlllued at morc than $5,0007 DVes D No

lhls .:untribtat0n ~ls:)l)cia[~d wtth a evt:nt \tS(CU iu Section L i?

DYes

Method of cDutJibution: D Clsll 0 Pcrsonul Check D Credit/Debit Card Payroll Deduction

lIe

Amoun( of Contrlbutiun Oyer

It' l'l\iJtribuliOll is in eXCess uC$400 to a candidate committee for " ;;hief execurive oftlcer of a lIIUlllClt>,rlli路Y does cOl\lribufur or busi'less lielshe is aSSOCiZl[cd wilh have a contract with said valued almore niaU $S,OOll? DYes D No DYes No

MelllOti of cOlltribufiOl1: D Casb D Persoual Check D Pelnoll Deduc[ion

D Crdil!Debit Card

If contribution is in excess of

executive officer of a

to a candidate committee municipality docs contributor or business he/she is a'Soclate.:! valued at more than $5 DYes

Is this contribution associared with a fundraising event listed in Section L 1? 11yes, list Event #

DYes ~No

Method of c9tribution: D Cash ,lZl""PersonaJ Check Payroll Deduction

0 CreditlDebit Card 0.00

.~~~~r-~~~~----~~-m,~~-m~~~-----------------1

Amount of Contribution

is in excess of $400 to a candidate committee for a chief executive officer of municipality does contnoutor or business he/she is associated with have a contract with said OYes valued at more than $5,0007

Is this contribution associated with a fundraising event listed in Section L I? 11yes, list Event #

Yes

'9- No

Method of contribution: Cash ~ersonal Check Payroll Deduction

o o

CreditlDebit Card

~~~~~~~~~~~~~~--~~~~~--~~~~--~~~~~----------~

Amount or Contribution

If contribution is excess of to a committee for a chief executive officer of a municipality does contributor or business he/she is associated with have a contract with said municipality valued at more than $5,0007 OYes 0-No

Is this contribution associated with a 0 Yes fundraising event listed in Section L I?,a-No Ilyes, list Event #

Method of contribution: 0 Cash ~ersonal Check D Payroll Deduction

CreditlDebit Card

Is this contribution associated with a 0 Ycs fundraising event listed in Section L I? ~o Ilyes, list Event #

Method of contribution: Cash .Ji?P'ersonal Check Payroll Deduction

o o

contribution is in excess municipality does contributor or valued at more than DYes No

jZ-

Method of contribution: 0 Cash Jih'ersonal Check Payroll Deduction

CreditIDcbit Card

~~~~~~--~~~~--~~~~--~~~~----------------~ If contribution is in excess of $400 to a candidate committee municipality does contributor or business he/she is asscx:ialted valued at more than $5,0007 OYes COIltnlbutlon associated with a 0 Yes Iturldn!llSlllg event listed in Section Ll? J2f"'No Event #

Method of contnbution: Cash j:tPersonal Check Payroll Deduction

o o

executive officer of a have a contract with said

Amount of Contribution

. treet Address

ljyes, list Event #

Amount of Contribution

Yes ljyes, list No Event #

Amount of Contribution

ljyes, list Event #

Amount of Contribution

ljyes, list Event #

Amount of Contribution

.arne

reetAddress

Is this contribution associated with a fundraisiog event listed in Section Ll?

0 0

. ~me of Committee

''1

\e!

Amount of Receipt

Reimbursement for shared expense Payment for goods and serviees

o Surplus Distribution

Amount of Receipt

Was this fundraising event hosted at a personal residence?

o Yes (If yes, go to Section lA In-kind Donations not Considered Contributions and complete required information for purchases made by host(s) for food, beverage and invitations.)

')id this fundraiser include items donated by a business entity of up to )100 or items donated by an individual of up to $50?

DYes (l[yes, go to Section lA In-kind Donations not Considered Contributions and complete required information.) Yes (l[yes, go to Section L2 Proceeds from Tag Sale, Auction, or Other Sale of Donated Items.)

Nas this fundraiser a tag sale, auction, or other sale of donated items?

'uhpart 2: (Town Committees and Municipal Candidate Committees ONLl2/

Were there purchases of advertising space in a program book associated with this fundraiser?

~ Yes if[yes, go to Section L3 Purchases of Advertising Space in a Program Book

and complete required information.)

Subpart 3: (Town Committees ONLy) Did your committee sell food or beverage at a fair or similar mass gathering held within the state?

DYes (Ifyes, enter Total Receipts from small purchases

here~ $_ ____.... LI

)Xl- No

Subpart 1: (All Committees) las this fundraising event hosted at a personal residence?

DYes (l[yes, go to Section lA In-kind Donations not Considered Contributions

and complete required information forpurebases made by host(s) for food,

beverage and invitations.)

id this fundraiser include items donated by a business entity of up to 100 or items donated by an individual of up to $50?

DYes (If yes, go to Seetion lA In-kind Donations not Considered Contrihutions

and complete required information.)

. 'as this fundraiser a tag sale, auction, or other sale of donated items?

DYes (l[yes, go to SectionL2 Proceeds from Tag Sale, Auction, or Other Sale of

Donated Items.)

ONo

ubpart 2: (Town Committees and Municipal Candidate Committees ONLy) ,!ere there purchases of advertising space in a program book associated ,"ith this fundraiser?

,:Jhpart 3: (Town Committees ONLy)

'id your committee sell food or beverage at a fair or similar mass :athering held within the state?

0 Yes (l[yes, go to Section L3 Purchases of Advertising Space in a Program Book

and complete required information.)

DYes (Ifyes, enter Total Receipts from small purchases bere~

,\..$_ ____....

o No

o Candidate

o Individual 0

Other

or Guarantor of this loan? Yes (ifyes list

name llJId address of Cosigner/GlUmmtor)

ONo

Is there a Cosigner or Guarantor of this loan? Yes (ifyes list

Amount Received

name arui address of Cosigner/Guarantor)

'treet Address

Amount Received

Amount Received ,y

Amount Received :y

.e of Receipt

his transaction associated with a draising event listed in Section L I?

lofReceipt

Date of Receipt

Amount

DYes No

qyes, list

Event# _ __

Method ofpayment:

Cash

Amount

Is this transaction associated with a 0 Yes fundraising event listed in Section Ll? 0 No

Date of Receipt

Total Transfers

qyes, list

Event# _ __

Method ofpayment:

o Cash

$1 bills

$5 bills

$1 bills

$5 bills

CQins

$10 bills

coins

$10 bills

;)ate of Receipt

Date of Receipt

\mount

Amount

'ame of Institution

Name of Institution

!reet Address

Street Address

ity

City

Total Amount Received

Amount Received

<ame

. arne

,'eel

Jtal Loans Received tbis Period (Section D) 'Jtal

Wp,<,pintc

from Entities other than Individuals

Other Committees ''''ftftn,._ E)

;Ital Amount Transferred from Affiliated Business Treasury (Section F)

)tal Amount Transferred from Affiliated Labor Union or Other Organization Treasury (Section G)

"Jtal Amount

;:;tal Amount of Anonymous Contributions (Section I) Interest from Deposits in Authorized

(Section J)

:)tal Miscellaneous Monetary Receipts not Considered Contributions (Section K)

+ +

CreditlDebit Card

Purchases Items

,lame ofPurebaser (Individuals

CreditlDebit Card

Aggregate Amount of Purchases

0 CreditlDebit Card

Aggregate Amount of Purchases

CreditlDebit Card

Aggregate Amount of Purchases

0 CreditlDebit Card

Aggregate Amount or Purchases

CreditlDebit Card

Aggregate Amount of Purchases

CreditlDebit Card

Aggregate Amount of Purchases

CreditIDebit Card

Aggregate Amount of Purchases

CreditlDebit Card

Aggregate Amount of Purchases

arne of Purchaser (Individuals ONL Y)

Jv1ethod of payment: Cash 0 Personal Check

Received

ameof

ONLY)

,Ime of Purchaser (Individuals ONL Y)

Method of payment o Cash 0 Personal Check Received

Event #

Metbod ofpayment: Cash 0 Personal Check

Date Received

Event #

:TIS

:J.:e

7570 0 for AU Events

7..r. Od

75"=00 Amount of

Purchase

7S-:00 Amouotof Purchase

7s-:00 Amount of Purchase

7,J;

O.&足

Amount of Purcbase

ICJs-. f!Jd Purchases

for All Events

/;2.5:

()O

Amouotof

Purchase

I;zo.oo Purchases

for All Events

Amouotof

Purchase

/tJG.C)CJ Amount of Purchase

c:201!J . 6-0 'Amouotof Purchase

lot!) .0(1 Amount of Purchase

/~.otl Amount of Purchase

I~06 Amount of Purchase

tfl.6tJ . t7C;

Amount of

Purchase

Amount of

Business Entity SIreet

Zip Code

DYes oNo

Purchase Event #

Name of Purchaser

Ini5~,c!5""

Purchases for All Events

Amount of

Purchase

Street Address

Name of Purchaser for All Events

Amount of Purchase

Street Address

Name of Purchaser

Amount of Entity Zip Code

Name of Purchaser

DYes DNo

for All Events

Purchase

for All Events

Amount of Purchase

Event #

Business Date Received Entity

Street Address

'lame of Purchaser

of Purchase Zip Code

Purchaser

'treet

:ame of Purchaser

Amount of

Purchase

Aggregate for All Events

Amount of

Purchase

Aggregate for All Events

Amount of Purchase

for All Events

Amo0nt of Purchase

Zip Code

'';ame of Purchaser

:treet Address

All Events

Zip Code

creet

arne of Purchaser

rect

Purchase

{LsO.dT; Amount of Purchase

.:J$lJ. ,::J() Amount of Purchase Street

City

Zip Code \,

. Name of Purchaser Entily Street Address

Zip Code

Name of Purchaser

Zip Code

Name of Purchaser

DYes

ONo

DYes

ONo

Name of Purchaser

DYes

ONo

'lame of Purchaser

Purchases for All Events

Amount of

Purchase

Purchases for All Events

Amount of

Purchase

Purchases for All Events

of Purchase

Event #

Business Date Received Entity

'3treet

Amount of

Purchase

Event #

Business Date Received Entity

Street

for All Event'

Event #

Business Date Received Entity

CIty

Amount of Purchase

Event #

Business Date Received Entity

Address

Street Address

DYes ONo

for All Events

DYes

DNa

of Purchaser Entity

'treet

Zip Code

',ame of Purchaser

for All Events

-Amount of Purchase

for All Events

Amount of

Purchase

for All Evellts

Amount of Purchase

DYes

ONo

Business Date Received Entity

DYes ONo

Event #

;ame of Purchaser

treet

City

arne of Purchaser

Amo~ntof

for All Events

Purchase

Type of Contributor: Individual Committee Other (Applicable only to Refetendum Committees)

o o o

Is contributor a lobbyist, spouse, or dependent child ofa lobbyist? Dale Received

If contribution is in excess of$4oo to a candidate committee for a chief executive officer of a municipality does contributor or business he/she is associated with have a contract with said valued at more than 0 Yes 0 No

Is this contribution associated with a fundraising event listed in Section Ll ? [/yes, list Event #

o o

Yes No Type of Contributor: lndividual Committee Other (Applicable only to Refetendum Committees)

o o

Value of this Contribution

Is contributor a lobbyist, spouse,

o o

If contribution is in excess 0[$400 to a candidate committee for a chief executive officer of a )r dependent child of a lobbyist? municipality does contributor or business he/she is associated with have a contract with said valued at more than $5,0007 0 Yes 0 No late Received Description of In-Kind ,""UllUlL'UU<Jll Is this contribution associated with a Yes fundraising event listed in Section L I ? [/yes,list Event #

o o

'lame

Type of Contnoutor: lndividual Committee Other (Applicable only to Referendum Committees)

o o o

contributor a lobbyist, spouse, '1r dependent child of a lobbyist?

If contribution is in exccss of $400 to a candidate committee for a chief executive officer of a

ate Received

municipality. does contributor or business he/she is associated with have a contract with said valued at more than $5,000? 0 Yes 0 No

Is this contribution associated with a fundraising event listed in Section LI? [/yes. list Event #

DYes No

arne

Type of Contributor: Individual Committee Other (Applkable only to Refetendum Committees)

o o

<reel

contnoutor a lobbyist, spouse, ,,- dependent child of a lobbyist? "Ie Received

Value of this Contribution

Value of this

Contribution

If contribution is in excess of $400 to a candidate committee for a chief executive officer of a

municipality does contributor or business he/she is associated with have a contract with said valued at more than $5,0007 0 Yes 0 No Description of In-Kind Contribution Is this contribution associated with a DYes fundraising event listed in Section Ll? No Ifyes. list Event #

Type of Contributor: Individual Committee Other (Applicable only to Referendum Committees)

o o o

,;eel

contributor a lobbyist, spouse, : dependent child of a lobbyist? _';e

Received

'TIC of

o o

If contribution is in excess of$4oo to a candidate committee

a chief executive officer of a municipality does contnoutor or business he/she is associated with have a contract with said valued at more than $5,000? 0 Yes 0 No

this contribution assoeiated with a fundraising event listed in Section L I ? Ifyes, list Event #

company

DYes No

of In-Kind

Value ofthis

Contribution

Name of Issuing Institution

Type of Credit Card:

Visa

Master Card

Discover

American Express

Other Date of Transaction

Amount

Date of TfllIlSaction

Amount

Date ofTransaction

Amount

Date of Trnnsaction

Amount

Date of Transaction

Amount

Date of Transaction

Amount

Date ofTransaction

Amount

Date ofTransacnon

Amount

Code

Purpose of Expenditure (by code)

Street

City

Pmpose of Expenditure (by code)

Purpose of Expenditure (by code) SameofVeodor

3treet Address

Code

,'urpose of Expenditure by code)

'lame of Vendor

'. treet Address

Code

urpose of Expenditure Jycode) ~ame

â&#x20AC;˘ ',Teet

City

:'.rrpose of Expenditure '_ y code) me

City

'rpose of Expenditure ;ycode) 'lleofVendor

DYes ~o

Is Reimbursement Claimed?

DYes

lil'No

Is Reimbursement Claimed? DYes

jZtNo

Is Reimbursement Claimed?

DYes Ql-No

Is Reimbursement Claimed?

DYes ~No

Claimed? DYes ~No

Is Reimbursement Claimed?

Dyes "'No

Is Reimbursement Claimed?

Date ofPayment

_~.~~~----------~~------~~~~----J

Is Reimbursement Claimed? DYes

DNo code)

Amount

(Estimau or Actual) ,treet Address

Description

Candidate(s) Name (if applicable)

ate Incurred

(if IlPpllcable):

o o o

Coordinated with reimbursement sought Coordinated without reimbursement lndependent Organization

o Supported

arne

Amount (Estimau or Actual)

.'ity

Sought

ate Incurred

(if IlPplicable):

o o o

Coordinated with reimbursement sought Coordinated without reimbursement sought Independent Organization

Supported

;arne

Amount (Estimau or Actual)

treet

Description

Name (if applicable) .ate Incurred

o o o ,l!De

of Creditor

reet

.. Jty

'lte Incurred

ofExpenditure (if IlPPllcable): Coordinated with reimbursement sought Coordinated without reimbursement sought lndependent Organization Purpose of Expenditure

Amount

(by code)

(Estimau or Actual)

Description

Name (if IlPpllcab/e)

Purpose

(by code)

o o

of Expenditure (if apptic4ble); Coordinated with reimbursement sought Coordinated without reimbursement sought Independent

Name of Worker/Consultant

Amount

Method of Payment DCheck#_ __

o Debit Card

Sought (if applicable)

PPurpowpo.s~e~~~fu;;---------------~---rTTyp;;e~o~f~E;.x~p;en~dfritur~e~a~ifr.ap;p;Ii~'~~bbik~~~;--------1 (by code)

0 Coordinated with reimbursement sought

o Coordinated without reimbursement sought

o Independent o

Supported

Name of Worker/Consultant

Amount

Method of Payment DCheck#_ __ Debit Card

Sought (if applicable)

p~~o.s~e~~~fu;;---------------~---rTT~;;~O~fnE~x;p~en~dili路ture~;a~ifr.ap;p;1i~'a~bbik~~~:--------1 <by code)

0 Coordinated with reimbursement sought

o Coordinated without reimbursement sought o Independent

o Name of Worker/Consultant

Amount

(if applicabk)

Purpose of Expenditure ;:by code)

:=--.--:-.-----------------------l

Type of Expenditure (if applicabk): Coordinated with reimbursement sought 0 Coordinated without reimbursement sought Independent

o Supported

Name of WorkerlConsultant

Amount

Method of Payment DCheck#_ __ Debit Card

Sought (if applicable)

?W~;;n;~~;e--------------L----rTf,yp~e~o~f~E~x;pen~di~路tur~e~aYif~ap;p~li~路a~b~k~~路~.--------1 J>Y code)

0 Coordinated with reimbursement sought

o Coordinated without reimbursement sought o Independent