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Page of 2017 CAMPAIGN FINANCE STATEMENT Due by 5:00 p.m. on December 7, 2017 Name of Candidate Address Ogden, UT Candidate for: Council Member – Municipal Ward 1 Council Member – Municipal Ward 3 Council Member – At-Large Seat A Council Member – At-Large Seat B For contributions received and expenditures made from October 28, 2017 to December 4, 2017. I, , as Candidate Secretary of the aforesaid personal campaign committee, certify that all contributions and expenditures not heretofore reported have been reported and that there are no bills or obligations outstanding or unpaid, except as set forth in this report. Signature of Candidate/Secretary of Committee 1 Balance carried forward from last report. (Summary of contributions, expenditures, loans & debts reported in previously filed financial statement.) $ 2 Total of all contributions of $50 or less during this reporting period. Number of contributors_______________ $ 3 Total of contributions from donors who gave more than $50 during this reporting period. (From the table in Attachment $ 4 Total contributions as of this report. (Add lines 2 and $ 5 Total expenditures made or obligations incurred during this reporting period. (From the table in Attachment $ 6 BALANCE AT THE END OF REPORTING PERIOD. (Add lines 1 and 4, then deduct line 5 for the balance.) $ ---PAGE BREAK--- Page of Attachment A CONTRIBUTIONS RECEIVED DATE RECEIVED NAME COMPLETE ADDRESS* AMOUNT PURPOSE TOTAL *Complete address required (Attach additional sheets if necessary) ---PAGE BREAK--- Page of Attachment B CAMPAIGN EXPENDITURES DATE OF EXPENDITURE DISBURSED TO COMPLETE ADDRESS* AMOUNT PURPOSE TOTAL *Complete address required (Attach additional sheets if necessary)