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<br /> PC2 <br /> Cash Contributions, Loans Received and In-Kind Rev. 12/03 <br />Candidate or Political Committee Name: Committee ID Number: <br />Vote Yes For External Police Review Page ~ of~ <br />Election: o Primary 20 [g] General 2005 o Other <br />Report: o I st Pre-election [g] 2nd Pre-election o Post-election o 20_ September Supplemental <br />SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS <br />CODE 1: Contributor Type CODE 2: Contribution Type <br /> B Business Entity CA Cash <br /> C Political Committee (includes business and union PACs) CO Cosigner Obligation <br /> F Candidate's Immediate Family (includes candidate) IK In-Kind <br /> I Individual LR Loan Received <br /> L Labor Organization <br /> 0 Other <br /> P Political Party Committee <br />Line # Name and Address of Contributor Amount of In-Kind Purpose <br /> Contribution (see manual for suggested purpose codes) <br />Date Received Occupational Information or Contributor Code 1 I Code 2 <br /> Contributing Committee's 10# Aggregate <br /> Andrea Ortiz <br />1. 189 Foch St. $ 74.54 G <br /> Eugene, OR 97402 <br />10/21/2005 Patient Access Specialist $ 715.11 I I IK <br />2. $ <br /> $ I <br />3. $ <br /> $ I <br />4. $ <br /> $ I <br />5. $ <br /> $ I <br />See Page Totals (Add all amounts with the same Accounting Period Totals (Complete only for last page and <br />Instructions contribution type. Do not include aggregates.) transfer these amounts to the Summary Statement, PC 1.) <br />on Back and Cash (CA) $ 0.00 Cash (CA) $ 3,767.00 <br />in Campaign Enter on Summary Statement, Column A, Line 1 <br />Finance In-Kind (IK) $ 1 ,093.42 <br />Manual In-Kind (IK) $ 74.54 <br /> Enter on Summary Statement, Cohunn A, Lines 4 and 9 <br />PC 2 Loans Received (LR) $ 0.00 Loans Received (LR) $ 0.00 <br /> Enter on SlUnmary Statement, Column A. Line 2 <br />