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Page 1 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 Campaign Contribution Disclosure Report Georgia Government Transparency and Campaign Finance Commission 200 Piedmont Avenue S.E. I Suite 1416 West Tower I Atlanta, GA 30334 I [PHONE REDACTED] I www.ethics.ga.gov 1. Report Type (Select One) Original Amendment Amendment # 2. Filing is being made on behalf of (Select One): Candidate or Public Official Office Held or Sought (Include county, municipality, district, post or judicial circuit) Filer ID (Filer ID that begins with the letter Organization or Person Other than Candidate’s Campaign Committee Committee Name: Filer ID: (Filer ID that begins with the letter “NC”) Use Earlier of Post Mark or Hand-Delivered Date 3. Identifying and Contact Information Full Name of Candidate or Other Than Candidate Campaign Committee Name Today’s Date Mailing Address City State Zip Code and/ or Primary Contact Phone Number E-Mail If a Candidate or Public Official is there a campaign committee (one or more persons) to make campaign transactions, keep financial records of the campaign or file the reports? Yes No If yes, is the committee registered with the Commission? Yes No If yes, complete the following: Name of Committee Chairperson Name of Committee Treasurer 4. Period for which you are Reporting You Must Check Only One Box My Non Election Year My Election Year Run-Offs (Report required only if you are in a Run-Off Election) Special Election January 31, (year) June 30, (year) December 31, (year) January 31, (year) April 30, (year) June 30, (year) September 30, (year) October 25, (year) Dec. 31, (year) 6 days before Primary Run-Off (year) 6 days before General Run-Off (year) 6 days before Special Primary Run-Off (year) 6 days before Special Run-Off (year) 15 days before S pecial Primary, (year) 15 days before Special, (year) Dec. 31, (year) Supplemental Reporting June 30, (year) December 31, (year) *Supplemental reports are required of candidates who have unsuccessfully campaigned for office or have resigned from office. See O.C.G.A. § 21-5- 34i State of County of I, , being duly sworn (affirm), depose and say that the information in this report form is complete, true, and correct. Further, I affirm that the contents in this report are the same as the contents in the electronic filing submitted, if also electronically filed. Sworn to and subscribed before me on , 20 Signature of Notary Public Commission Expiration a. Signature of Candidate b. Organization/Chairperson/Treasurer SIGN SIGN ---PAGE BREAK--- Page 2 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 State of Georgia Campaign Contribution Disclosure Report Summary Report CONTRIBUTIONS RECEIVED 1 I have no contributions to report. I have the following contributions, including Common Source, to report: In-Kind Estimated Value Cash Amount 2 A. If this is the first time to file a disclosure report for the current office sought, ENTER 0 in both columns (one time only); or B. If this is the first report of this Election Cycle*, ENTER 0 in the in-kind column and list any net balance on hand brought forward from the previous election cycle in the cash amount column (Line 15 of previous report, or total funds left over at year end of previous cycle); or C. If this filing is the second or subsequent filing of this Election Cycle, list totals from Line 6 of previous report in both the in-kind and cash amount columns. 3 Total amount of all itemized contributions received in this reporting period which is listed on the "Itemized Contributions" page. 3a All loans received this reporting period. 3b Interest earned on campaign account this reporting period. 3c Total amount of investments sold this reporting period. 3d Total amount of cash dividends and interest paid out this reporting period. 4 Total amount of all separate contributions of $100 or less received in this reporting period and not listed on the "Itemized Contributions" page. "Common Source" contributions must be aggregated on the "Itemized Contributions" page. 5 Total contributions reported this period. (Line 3 + 3a + 3b + 3c + 3d + 4) 6 Total contributions to date. Total to be carried forward to next report of this election cycle*. (Line 2 + 5) EXPENDITURES MADE 7 I have no expenditures to report. I have the following expenditures to report: 8 Total expenditures made and reported prior to this reporting period. If this is the A. First report of this Election Cycle*, ENTER 0. B. Second or subsequent filing ENTER Line 12 of previous report. 9 Total amount of all itemized expenditures made in this reporting period which are listed on the "Itemized Expenditures" page. 10 Total amount of all separate expenditures of $100.00 or less that were made in this reporting period and not listed on the "Itemized Expenditures" page 11 Total expenditures reported this period. (Line 9 + 10) 12 Total expenditures to date. Total to be carried forward to next report of this election cycle*. (Line 8 + 11) INVESTMENTS 13 Total value of investments held at the beginning of this reporting period. 14 Total value of investments held at the end of this reporting period. TOTAL NET BALANCE ON HAND 15 Net balance on hand. (Line 6 - 12 + 14) * O.C.G.A. 21-5-3(10) : Election cycle means the period from the day following the date of an election or appointment of a person to elective public office through and of the next such election of a person to the same public office and shall be construed and applied separately for each elective office including the date. ---PAGE BREAK--- Page 3 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 State of Georgia Campaign Contribution Disclosure Report Outstanding Indebtness Election Cycle*: Election Year: Amount 1 Outstanding indebtedness at the beginning of this reporting period. 2 Loans received this reporting period. 3 Deferred payment of expenses this reporting period 4 Payments made on loans this reporting period. 5 Credits received on loans this reporting period 6 Payments this reporting period on previously deferred expenses. 7 Total indebtedness at the close of this reporting period. (Line 1 + 2 + 3 - 4 - 5 - 6) Election Cycle*: Election Year: Amount 1 Outstanding indebtedness at the beginning of this reporting period. 2 Loans received this reporting period. 3 Deferred payment of expenses this reporting period 4 Payments made on loans this reporting period. 5 Credits received on loans this reporting period 6 Payments this reporting period on previously deferred expenses. 7 Total indebtedness at the close of this reporting period. (Line 1 + 2 + 3 - 4 - 5 - 6) Election Cycle*: Election Year: Amount 1 Outstanding indebtedness at the beginning of this reporting period. 2 Loans received this reporting period. 3 Deferred payment of expenses this reporting period 4 Payments made on loans this reporting period. 5 Credits received on loans this reporting period 6 Payments this reporting period on previously deferred expenses. 7 Total indebtedness at the close of this reporting period. (Line 1 + 2 + 3 - 4 - 5 - 6) * Election Cycle (Primary, General, Special, Special Primary, Run-Off Primary, Run-Off General, Run-Off Special, Run-Off Special Primary) Public Officer/Candidate/Other Than Candidate Committee Name ---PAGE BREAK--- Page 4 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 State of Georgia Campaign Contribution Disclosure Report Itemized Contributions Must list contributions received by a single contributor for which the aggregate total more than $100.00. Note: Loans are no longer reported in “Itemized Contributions” section. See Loan Reporting section below. Full Name of Contributor Mailing Address (Affiliation of Committee if any) Contributor Election Cycle** Cash Amount In-Kind Contributions Received Date Contribution Type* Occupation & Employer Estimated Value Description First Name or Business Name Date Occupation Primary General Special Special Primary Run-Off Primary Run-Off General Cash Amt. Est. Value Last Name Address Run-Off Special Address2 Monetary In-Kind Common Source Credit Received on Loan Employer Run-Off Special Primary Description City State Zip Aff. Comm. First Name or Business Name Date Occupation Primary General Special Special Primary Run-Off Primary Run-Off General Cash Amt. Est. Value Last Name Address Run-Off Special Address2 Monetary In-Kind Common Source Credit Received on Loan Employer Run-Off Special Primary Description City State Zip Aff. Comm. First Name or Business Name Date Occupation Primary General Special Special Primary Run-Off Primary Run-Off General Run-Off Special Run-Off Special Primary Cash Amt. Est. Value Last Name Address Address2 Monetary In-Kind Common Source Credit Received on Loan Employer Description City State Zip Aff. Comm. Itemized Contributions Page Total $ $ ---PAGE BREAK--- Page 5 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 First Name or Business Name Date Occupation Primary General Special Special Primary Run-Off Primary Run-Off General Run-Off Special Run-Off Special Primary Cash Amt. Est. Value Last Name Address Address2 Monetary In-Kind Common Source Credit Received on Loan Employer Description City State Zip Aff. Comm. First Name or Business Name Date Occupation Primary General Special Special Primary Run-Off Primary Run-Off General Run-Off Special Run-Off Special Primary Cash Amt. Est. Value Last Name Address Address2 Monetary In-Kind Common Source Credit Received on Loan Employer Description City State Zip Aff. Comm. First Name or Business Name Date Occupation Primary General Special Special Primary Run-Off Primary Run-Off General Run-Off Special Run-Off Special Primary Cash Amt. Est. Value Last Name Address Address2 Monetary In-Kind Common Source Credit Received on Loan Employer Description City State Zip Aff. Comm. First Name or Business Name Date Occupation Primary General Special Special Primary Run-Off Primary Run-Off General Run-Off Special Run-Off Special Primary Cash Amt. Est. Value Last Name Address Address2 Monetary In-Kind Common Source Credit Received on Loan Employer Description City State Zip Aff. Comm. Itemized Contributions Page Total $ $ * Contribution Type (Monetary, In-Kind, Common Source, Credit Received on Loan) Election Cycle (Primary, General, Special, Special Primary, Run-Off Primary, Run-Off General, Run-Off Special, Run-Off Special Primary) If any such person(s) shall have a fiduciary relationship to the lending institution or party making the advance or extension of credit ---PAGE BREAK--- Page 6 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 Loan Reporting Name of Lender & Mailing Address 1. Date of Loan 2. Amount of Loan 3.Election Cycle** Person(s) responsible for repayment of loan & Mailing Address 1.Occupation & 2.Place of Employment 3.Fiduciary Relationship*** Lender Name (First Name, Business, Inst.) 1. First Name 1. Lender Last Name 2. Last Name 2. Address 3. Primary General Special Special Primary Run-Off Primary Run-Off General Run-Off Special Run-Off Special Primary Address 3. Public Officer Candidate Other Than Candidate Committee Name Address2 Address2 City City State Zip State Zip Lender Name (First Name, Business, Inst.) 1. First Name 1. Lender Last Name 2. Last Name 2. Address 3. Primary General Special Special Primary Run-Off Primary Run-Off General Run-Off Special Run-Off Special Primary Address 3. Public Officer Candidate Other Than Candidate Committee Name Address2 Address2 City City State Zip State Zip Reference: OCGA § 21-5-34(b)(1) Loan Page Total $ * Contribution Type (Monetary, In-Kind, Common Source, Credit Received on Loan) Election Cycle (Primary, General, Special, Special Primary, Run-Off Primary, Run-Off General, Run-Off Special, Run-Off Special Primary) If any such person(s) shall have a fiduciary relationship to the lending institution or party making the advance or extension of credit ---PAGE BREAK--- Page 7 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 State of Georgia Campaign Contribution Disclosure Report Itemized Expenditures Must list expenditures made to a single recipient for which the aggregate total more than $100.00. List Name and Mailing Address of Recipient Exp. Date Exp. Type* Occupation & Employer Expenditure Purpose Amount Paid First Name Date Occupation Last Name Address Expenditure In-Kind Loan Repayment Refund Reimbursement Credit Card Address2 Employer City 3rd Party Deferred Payment Payment on Deferred Expense Investment State Zip First Name Date Occupation Last Name Address Expenditure In-Kind Loan Repayment Refund Reimbursement Credit Card Address2 Employer City 3rd Party Deferred Payment Payment on Deferred Expense Investment State Zip First Name Date Occupation Last Name Address Expenditure In-Kind Loan Repayment Refund Reimbursement Credit Card Address2 Employer City 3rd Party Deferred Payment Payment on Deferred Expense Investment State Zip Page Total $ * Expenditure Type (Expenditure, In-Kind, Loan Repayment, Refund, Reimbursement, Credit Card, 3rd Party, Deferred Payment on Deferred Expense, Investment) Public Officer/Candidate/Other Than Candidate Committee Name ---PAGE BREAK--- Page 8 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 List Name and Mailing Address of Recipient Exp. Date Exp. Type* Occupation & Employer Expenditure Purpose Amount Paid First Name Date Occupation Last Name Address Expenditure In-Kind Loan Repayment Refund Reimbursement Credit Card Address2 Employer City 3rd Party Deferred Payment Payment on Deferred Expense State Zip Investment First Name Date Occupation Last Name Address Expenditure In-Kind Loan Repayment Refund Reimbursement Credit Card Address2 Employer City 3rd Party Deferred Payment Payment on Deferred Expense Investment State Zip First Name Date Occupation Last Name Address Expenditure In-Kind Loan Repayment Refund Reimbursement Credit Card Address2 Employer City 3rd Party Deferred Payment Payment on Deferred Expense Investment State Zip First Name Date Occupation Last Name Address Expenditure In-Kind Loan Repayment Refund Reimbursement Credit Card Address2 Employer City 3rd Party Deferred Payment Payment on Deferred Expense Investment State Zip * Expenditure Type (Expenditure, In-Kind, Loan Repayment, Refund, Reimbursement, Credit Card, 3rd Party, Deferred Payment on Deferred Expense, Investment)Public Officer/Candidate/Other Than Candidate Committee Name Page Total $ ---PAGE BREAK--- Page 9 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/19 State of Georgia Campaign Contribution Disclosure Report Investments Statement 1. Investment Name Account # Value at beginning of reporting period $ Institution/Person Holding Account Value at end of reporting period $ Mailing Address Difference in value $ Address2 _ Interest Paid Out $ City State Zip Cash Dividends $ Investment Transactions Date Person(s) Involved in Transaction Value of investment purchased Value of investment sold Profit Loss 2. Investment Name Account # Institution/Person Holding Account Mailing Address Address2 City State Zip Value at beginning of reporting period $ Value at end of reporting period $ Difference in value $ Interest Paid Out $ Cash Dividends $ Investment Transactions Date Person(s) Involved in Transaction Value of investment purchased Value of investment sold Profit Loss Total value of investments at beginning of reporting period $ Total value of investments at end of reporting period $ Total difference in value $ Page Total Cash Dividends: $ Page Total Interest Paid Out: $ Page Total Profit: $ Page Total Loss: $ ---PAGE BREAK--- Page 10 of 10 Public Officer/Candidate/Other Than Candidate Committee Name Page of CFC-CCDR 10/1 State of Georgia Campaign Contribution Disclosure Report Addendum Statement The Addendum Statement should be used for explanation of any additional information needed to complete an accurate filing of this report. Information that is to be reported in the body of the report should not be listed on Addendum Statement.