HomeMy WebLinkAboutWrite-In Jim Torrey
Summary Statement of Contributions and Expenditures PC 1
Rev. 12/03
Please type or print legibly in black ink. Page lof2
Candidate or Political Committee Name (use full name):
Write-In Jim Torrey
Mailing Address as it Appears on Statement of Organization (street, route or box number, city, state, zip code):
C/O Jones & Roth, PC PO Box 10086 Euqene, OR 97440
Treasurer's Name: I Telephone Number (day):
Tricia Duncan 541-687 -2320
Committee ID Number: Committee Type, Measure Number or Office:
None Mayor, City of Eugene
[8] Original D Primary 20_ D General 20_ D Other _
D Amendment D I st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
A-TOTALS FOR THIS B-CUMULA TIVE TOTALS
ACCOUNTING PERIOD FOR THIS ELECTION
CONTRIBUTIONS
I. Cash Contributions 6,770.00 28,005.00
(Accounting Period Total from PC 2)
2. Loans Received (Non-Exempt) + 0.00 + 16,400.00
(Accounting Period Total from PC 2)
3. Total Cash Contributions = 6,770.00 = 44,405.00
(lines 1+ 2)
4. In-Kind + 203.50 + 703.50
(Accounting Period Total from PC 2)
5. TOTAL CONTRIBUTIONS = 6,973.50 = 45,108.50
(lines 3 + 4)
EXPENDITURES
6. Cash Expenditures 1,009.50 28,342.64
(Accounting Period Total from PC 3)
7. Loan Payments (Non-Exempt) + 8,062.36 + 16,062.36
(Accounting Period Total from PC 3)
8. Total Cash Expenditures = 9,071.86 = 44,405.00
(lines 6 + 7)
9. In-Kind + 203.50 + 703.50
(Accounting Period Total from PC 2)
10. TOTAL EXPENDITURES = 9,275.36 = 45,108.50
(lines 8 + 9) I
CASH BALANCE
II. Beginning Cash Balance 2,301.86 FOR OFFICE USE ONL Y
(line 20 of previous report)
12. Total Contributions + 6,973.50
(line 5)
13. Other Receipts + 0.00 RECEIVED
(Accounting Period Total from PC 4A)
14. Loans Received (Exempt) + 0.00
(Accounting Period Total from PC 4A) SEP 0 6 2005
15. CONTRIBUTION SUBTOTAL = 9,275.36
(lines 11 + 12 + 13 + 14) CITY RECORDER
16. Total Expenditures 9,275.36
(line 10)
17. Other Disbursements + 0.00
(Accounting: Period Total from PC 4B)
18. Loan Payments (Exempt) + 0.00
(Accounting Period Total ITom PC 4B)
19. EXPENDITURE SUBTOTAL = 9,275.36
(lines 16 + 17 + 18)
20. ENDING CASH BALANCE = 0.00
(line 15 minus line 19)
Summary Statement of Contributions and Expenditures PC 1
Rev. 12/03
Please type or print legibly in black ink. Page 2 of2
Candidate or Political Committee Name: I Committee ID Number:
Write-In Jim Torrey None
D Original D Primary 20_ D General 20_ D Other _
D Amendment D 1 st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
LOAN SUMMARY FOR OFFICE USE ONLY
2I. Beginning Outstanding Loans
(line 29 of previous report) 8,400.00
22. Loans Received (Non-Exempt) + 0.00
(line 2)
23. Loans Received (Exempt) + 0.00
(line 14)
24. LOANS RECEIVED SUB TOT AL = 0.00
(lines 21 + 22 + 23)
25. Loan Payments (Non-Exempt) 8,063.36
(line 7)
26. Loan Payments (Exempt) + 0.00
(line 18)
27. Forgiven Loans + 337.64
(Total loans forgiven during this accounting period)
28. LOAN PAYMENT SUBTOTAL = 8,400.00
(lines 25 + 26 +27)
29. TOTAL OUTSTANDING LOANS = 0.00
(line 24 minus line 28)
PERSONAL EXPENDITURE SUMMARY
30. Beginning Outstanding Personal Expenditures 0.00
(line 36 of previous report)
3I. Personal Expenditures + 0.00
(Accounting Period Total from PC 3A)
32. PERSONAL EXPENDITURE SUBTOTAL = 0.00
(lines 30 + 31)
33. Personal Expenditure Reimbursements 0.00
(Total expenditures on PC 3 with purpose code R)
34. Forgiven Personal Expenditures + 0.00
(Total personal expenditures forgiven this acctg. period)
35. REIMBURSEMENT SUB TOT AL = 0.00
(lines 33 + 34)
36. OUTSTANDING PERSONAL EXPENDITURES = 0.00
(line 32 minus line 35)
FINANCIAL STATUS AT CLOSE OF ACCOUNTING PERIOD
37. Ending Cash Balance 0.00
(line 20)
38. Accounts Receivable + 0.00
(Accounting Period Total from PC 5)
39. SUBTOTAL = 0.00
(lines 37 + 38)
40. Total Outstanding Loans 0.00
(line 29)
4I. Outstanding Personal Expenditures + 0.00
(line 36)
42. Accounts Payable + 0.00
(Accounting Period Total ITom PC 6)
43. SUBTOTAL = 0.00
(lines 40 + 41 + 42)
44. BALANCE/DEFICIT = 0.00
(line 39 minus line 43: indicate + or - balance)
I, Tricia.-Ouncan (name of candidate or treasurer), hereby certify that the above statement and the attached supporting reports are
true fc( correct.
c;/61o)
~ 1A
Signature of cahdidate or treasurer Date ~igneB
PC 2
Cash Contributions, Loans Received and In-Kind Rev. 12/03
Candidate or Political Committee Name: Committee ID Number:
Write-In Jim Torrey None Page 1 ofZ
Election: D Primary 20_ D General 20_ D Other _
Report: D 1 st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS
CODE 1: Contributor Type CODE 2: Contribution Type
B Business Entity CA Cash
C Political Committee (includes business and union PACs) CO Cosigner Obligation
F Candidate's Immediate Family (includes candidate) IK In-Kind
I Individual LR Loan Received
L Labor Organization
0 Other
P Political Party Committee
Line # Name and Address of Contributor Amount of In-Kind Purpose
Contribution (see manual for suggested purpose codes)
Date Received Occupational Information or Contributor Code 1 I Code 2
Contributing Committee's 10# Aggregate
C.W. Walker & Associates
1. PO Box 1338 $ 100.00
Eugene, OR 97440
5-9-05 $ 100.00 B I CA
Stingray Holdings, LLC
2. PO Box 5042 $ 500.00
Eugene, OR 97405
5-12-05 $ 500.00 B I CA
Linda Korth
3. 2955 Metolius Drive $ 100.00
Eugene, OR 97401
5-5-2005 Real estate developer $ 100.00 I I CA
Joan Obie
4. 3694 Plumtree $ 203.50 Printing/Postage
Eugene, OR 97402
5-5-05 Bookkeeper $ 803.50 I I IK
Ed King
5. 30414 Le Bleu Road $ 100.00
Eugene, OR 97405
5-5-05 Retired $ 100.00 I I CA
See Page Totals (Add all amounts with the same Accounting Period Totals (Complete only for last page and
Instructions contribution type. Do not include aggregates.) transfer these amounts to the Summary Statement, PC I.)
on Back and Cash (CA) $ 800.00 Cash (CA) $
-
in Campaign Enter on Swnmary Statement, Column A, Line 1
Finance In-Kind (IK) $
Manual In-Kind (IK) $ 203.50 -
Enter on Summary Statement, Column A, Lines 4 and 9
pe2 Loans Received (LR) $ 0.00 Loans Received (LR) $ -
Enter on Swnmary Statement, Co1unm A, Line 2
PC 2
Cash Contributions, Loans Received and In-Kind Rev. 12/03
Candidate or Political Committee Name: Committee ID Number:
Write-In Jim Torrey None Page.f. ofZ
Election: D Primary 20_ D General 20_ D Other _
Report: D 1 st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS
CODE 1: Contributor Type CODE 2: Contribution Type
B Business Entity CA Cash
C Political Committee (includes business and union PACs) CO Cosigner Obligation
F Candidate's Immediate Family (includes candidate) IK In-Kind
I Individual LR Loan Received
L Labor Organization
0 Other
P Political Party Committee
Line # Name and Address of Contributor Amount of In-Kind Purpose
Contribution (see manual for suggested purpose codes)
Date Received Occupational Information or Contributor Code 1 I Code 2
Contributing Committee's ID# Aggregate
Yvonne Wild ish
1. 2390 McLean Blvd $ 300.00
Eugene, OR 97405
5-5-05 Retired $ 300.00 I I CA
Donald Ritchie
2. 4975 Blanton Road $ 100.00
Eugene, OR 97405
5-5-05 Retail store owner $ 100.00 I I CA
John Murphy
3. 3993 Spring Blvd $ 200.00
Eugene, OR 97405
5-5-05 Lumber broker $ 200.00 I I CA
Richard Hansen
4. 2744 Tomahawk $ 100.00
Eugene, OR 97401
5-5-05 Retired $ 100.00 I I CA
Ed Anderson
5. 621 Spyglass $ 100.00
Eugene, OR 97401
5-9-05 Retired $ 100.00 I I CA
See Page Totals (Add all amounts with the same Accounting Period Totals (Complete only for last page and
Instructions contribution type. Do not include aggregates.) transfer these amounts to the Summary Statement, PC I.)
on Back and Cash (CA) $ 800.00 Cash (CA) $
in Campaign -
Enter on Summary Statement, Column A, Line 1
Finance In-Kind (IK) $
Manual In-Kind (IK) $ 0.00
Enter on Summary Statement, Column A, Lines 4 and 9
pe2 Loans Received (LR) $ 0.00 I Loans Received (LR) $ -
Enter on Summary Statement, Column A, Line 2
PC 2
Cash Contributions, Loans Received and In-Kind Rev. 12/03
Candidate or Political Committee Name: Committee ID Number:
Write-In Jim Torrey None Page ~ ofZ
Election: D Primary 20_ D General 20_ D Other _
Report: D 1 st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS
CODE 1: Contributor Type CODE 2: Contribution Type
B Business Entity CA Cash
C Political Committee (includes business and union PACs) CO Cosigner Obligation
F Candidate's Immediate Family (includes candidate) IK In-Kind
I Individual LR Loan Received
L Labor Organization
0 Other
P Political Party Committee
Line # Name and Address of Contributor Amount of In-Kind Purpose
Contribution (see manual for suggested purpose codes)
Date Received Occupational Information or Contributor Code 1 I Code 2
Contributing Committee's ID# Aggregate
Ruth Nill
1. 653 Spyglass $ 100.00
Eugene, OR 97401
5-9-05 Homemaker $ 100.00 I I CA
Donna P. Woolley
2. Box 43 $ 200.00
Drain, OR 97435
5-9-05 Real estate broker $ 200.00 I I CA
Avon Lee Babb
3. 645 Spyglass Drive $ 100.00
Eugene, OR 97401
5-1 0-05 Sand and gravel $ 100.00 I I CA
Frederic Wittkop
4. 195 Madison St. $ 250.00
Eugene, OR 97402
5-10-05 Electrician $ 250.00 I I CA
Robert Ballin
5. PO Box 1357 $ 250.00
Eugene, OR 97440
5-12-05 Insurance sales $ 250.00 I I CA
See Page Totals (Add all amounts with the same Accounting Period Totals (Complete only for last page and
Instructions contribution type. Do not include aggregates.) transfer these amounts to the Summary Statement, PC 1.)
on Back and Cash (CA) $ 900.00 Cash (CA) $
-
in Campaign Enter on Swnmary Statement. Colwnn A, Line I
Finance $
Manual In-Kind (IK) $ 0.00 In-Kind (IK) -
Enter on Summary Statement, ColWlUl A, Lines 4 and 9
PC2 Loans Received (LR) $ 0.00 Loans Received (LR) $ -
Enter on Swnmary Statement, Co1WlU1 A, Line 2
PC 2
Cash Contributions, Loans Received and In-Kind Rev. 12/03
Candidate or Political Committee Name: Committee ID Number:
Write-In Jim Torrey None Page 1. ofZ
Election: D Primary 20_ D General 20_ D Other _
Report: D 1 st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS
CODE 1: Contributor Type CODE 2: Contribution Type
B Business Entity CA Cash
C Political Committee (includes business and union PACs) CO Cosigner Obligation
F Candidate's Immediate Family (includes candidate) IK In-Kind
I Individual LR Loan Received
L Labor Organization
0 Other
P Political Party Committee
Line # Name and Address of Contributor Amount of In-Kind Purpose
Contribution (see manual for suggested purpose codes)
Date Received Occupational Information or Contributor Code 1 I Code 2
Contributing Committee's ID# Aggregate
Jack Roberts
1. 2330 Park Grove Drive $ 250.00
Eugene, OR 97408
5-12-05 Executive director, nonproft $ 250.00 I I CA
Ruth Nill
2. 653 Spyglass Drive $ 100.00
Eugene, OR 97401
5-12-05 Homemaker $ 200.00 I I CA
Dave Swenson
3. 616 Power $ 100.00
Eugene, OR 97402
5-12-05 Automotive paint supplier $ 100.00 I I CA
Kay T oolson
4. 87180 Oakdale Drive $ 200.00
Eugene, OR 97402
5-12-05 RV Manufacturer $ 1,200.00 I I CA
Steve Romania
5. 1645 Williamsburg Way $ 100.00
Eugene, OR 97401
5-12-05 Retired $ 100.00 I I CA
See Page Totals (Add all amounts with the same Accounting Period Totals (Complete only for last page and
Instructions contribution type. Do not include aggregates.) transfer these amounts to the Summary Statement, PC 1.)
on Back and Cash (CA) $ 750.00 Cash (CA) $
in Campaign -
Enter on Summary Statement. Colwnn A, Line 1
Finance In-Kind (IK) $
Manual In-Kind (IK) $ 0.00 -
Enter on SWlllllary Statement, Colwnn A, Lines 4 and 9
pe2 Loans Received (LR) $ 0.00 Loans Received (LR) $ -
Enter on Swnmary Statement, Co1wnn A, Line 2
PC 2
Cash Contributions, Loans Received and In-Kind Rev. 12/03
Candidate or Political Committee Name: Committee ID Number:
Write-In Jim Torrey None Page ~ ofZ
Election: D Primary 20_ D General 20_ D Other _
Report: D I st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS
CODE 1: Contributor Type CODE 2: Contribution Type
B Business Entity CA Cash
C Political Committee (includes business and union PACs) CO Cosigner Obligation
F Candidate's Immediate Family (includes candidate) IK In-Kind
I Individual LR Loan Received
L Labor Organization
0 Other
P Political Party Committee
Line # Name and Address of Contributor Amount of In-Kind Purpose
Contribution (see manual for suggested purpose codes)
Date Received Occupational Information or Contributor Code 1 I Code 2
Contributing Committee's ID# Aggregate
Todd Torrey
1. 3593 River Pointe Drive $ 100.00
Eugene, OR 97408
5-12-05 Advertising sales $ 100.00 I I CA
Dixie Harrison
2. 29179 Spencer Creek Road $ 200.00
Eugene, OR 97405
5-12-05 Homemaker $ 200.00 I I CA
Shannon Nill
3. 91502 Coburg Road $ 100.00
Eugene, OR 97408
5-12-05 Auto sales $ 100.00 I I CA
Allan Emrick
4. 90680 Coburghills Drive $ 100.00
Eugene, OR 97408-9278
5-18-05 Lumber broker $ 100.00 I I CA
Stan Potter
5. 89939 Greenwood Drive $ 100.00
Leaburg, OR 97489
5-18-05 Attorney $ 100.00 I I CA
See Page Totals (Add all amounts with the same Accounting Period Totals (Complete only for last page and
Instructions contribution type. Do not include aggregates.) transfer these amounts to the Summary Statement, PC I.)
on Back and Cash (CA) $ 600.00 Cash (CA) $
in Campaign -
Enter on Swnmary Statement, Column A, Line 1
Finance $
Manual In-Kind (IK) $ 0.00 In-Kind (IK) -
Enter on Summary Statement, Co1Wlm A, Lines 4 and 9
pe2 Loans Received (LR) $ 0.00 Loans Received (LR) $ -
Enter on Summary Statement, Colwnn A, Line 2
PC 2
Cash Contributions, Loans Received and In-Kind Rev. 12/03
Candidate or Political Committee Name: Committee ID Number:
Write-In Jim Torrey None Page Q ofZ
Election: D Primary 20_ D General 20_ D Other _
Report: D I st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS
CODE 1: Contributor Type CODE 2: Contribution Type
B Business Entity CA Cash
C Political Committee (includes business and union P ACs) CO Cosigner Obligation
F Candidate's Immediate Family (includes candidate) IK In-Kind
I Individual LR Loan Received
L Labor Organization
0 Other
P Political Party Committee
Line # Name and Address of Contributor Amount of In-Kind Purpose
Contribution (see manual for suggested purpose codes)
Date Received Occupational Information or Contributor Code 1 I Code 2
Contributing Committee's ID# Aggregate
Miscellaneous contributions < $50
1. $ 170.00
various $ 170.00 I I CA
Miscellaneous contributsions < $50
2. $ 50.00
varous $ 50.00 B I CA
Wildish Sand and Gravel
3. PO Box 7428 $ 500.00
Eugene, OR 97401
12-22-04 $ 1,000.00 B I CA
T od Woodard
4. 1215 Courtney Place $ . 200.00
Eugene, OR 97405
12-22-04 Student $ 200.00 I I CA
J.H. Gonyea III
5. $ 1,000.00
12-22-04 Lumber broker $ 2,000.00 I I CA
See Page Totals (Add all amounts with the same Accounting Period Totals (Complete only for last page and
Instructions contribution type. Do not include aggregates.) transfer these amounts to the Summary Statement, PC I.)
on Back and Cash (CA) $ 1 ,920.00 Cash (CA) $
-
in Campaign Enter on Summary Statement, Column A, Line 1
Finance In-Kind (IK) $
Manual In-Kind (IK) $ 0.00 -
Enter on Swnmary Statement, Colwnn A, Lines 4 and 9
pe2 Loans Received (LR) $ 0.00 Loans Received (LR) $ -
Enter on Summary Statement, Colwnn A, Line 2
PC 2
Cash Contributions, Loans Received and In-Kind Rev. 12/03
Candidate or Political Committee Name: Committee ID Number:
Write-In Jim Torrey None Page Z ofZ
Election: D Primary 20_ D General 20_ D Other _
Report: D 1 st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS
CODE 1: Contributor Type CODE 2: Contribution Type
B Business Entity CA Cash
C Political Committee (includes business and union PACs) CO Cosigner Obligation
F Candidate's Immediate Family (includes candidate) IK In-Kind
I Individual LR Loan Received
L Labor Organization
0 Other
P Political Party Committee
Line # Name and Address of Contributor Amount of In-Kind Purpose
Contribution (see manual for suggested purpose codes)
Date Received Occupational Information or Contributor Code 1 I Code 2
Contributing Committee's ID# Aggregate
Thieles, LLC
1. PO Box 529 $ 1,000.00
Eugene, OR 97440
11-30-04 $ 1,000.00 B I CA
2. $
$ I
3. $
$ I
4. $
$ I
5. $
$ I
See Page Totals (Add all amounts with the same Accounting Period Totals (Complete only for last page and
Instructions contribution type. Do not include aggregates.) transfer these amounts to the Summary Statement, PC 1.)
on Back and Cash (CA) $ 1.000.00 Cash (CA) $ 6,770.00
in Campaign Enter on Summary Statement, ColWlID A, Line 1
Finance In-Kind (IK) $ 203.50
Manual In-Kind (IK) $ 0.00
Enter on Summary Statement, Column A, Lines 4 and 9
pe2 Loans Received (LR) $ 0.00 Loans Received (LR) $ 0.00
Enter on Swnmary Statement, ColWlID A. Line 2
PC 3
Cash Expenditures and Loan Payments Rev. 12/03
Candidate or Political Committee Name: Committee ID Number:
Write-In Jim Torrey None Page 1 of 1
Election: D Primary 20_ D General 20_ D Other _
Report: D 1 st Pre-election D 2nd Pre-election D Post-election [8] 2005 September Supplemental
PURPOSE CODES (see back of form for instructions and code definitions) EXPENDITURE TYPES
A Agent 0 Other Advertising (yard signs, buttons, etc.) CA Cash
B Broadcast Advertising (Radio, TV) P Postage LP Loan Payment
C Cash Contributions R Reimbursement for Personal Expenditures
F Fundraising Event Expenses S Surveys and Polls
G General Operational Expenses (describe if over $50) T Travel Expenses (describe if over $50)
I Interest Payment U Utilities
L Literature, Brochures, Printing W Wages, Salaries, Benefits
M Management Services y Petition Circulators
N Newspaper and Other Periodical Advertising Z Preparation and Production of Advertising
Payee's Name and Payee's Committee ID#, Exp. Amount of ~
Line # Date Check # if applicable Purpose Type Expenditure Paid
(as it appears on invoice, receipt or check) to AlP
1. 12-08-04 510 Jeff Miller Loan repay LP $ 2,700.00 D
2. 12-22-04 512 Jeff Miller Loan repay LP $ 1,700.00 D
3. 12-28-04 511 Sign Pro 0 CA $ 217.50 D
4. 5-23-05 513 Waterfront Restaurant F CA $ 792.00 D
5. 5-23-05 515 Jeff Miller Loan repay LP $ 3,662.36 D
6. $ D
7. $ D
8. $ D
9. $ D
10. $ D
See Page Totals (Add all expenditures with the same Accounting Period Totals (Complete only for last page and
Instructions expenditure type.) transfer these amounts to the Summary Statement, PC 1.)
on Back and Cash (CA) $ 1.009.50 Cash (CA) $ 1 ,009.50
in Campaign
Finance Enter on Summary Statement, Column A, Line 6
Manual Loan Payment (LP) $ 8.062.36 Loan Payment (LP) $ 8.062.36
Enter on Summary Statement, Column A, Line 7
PC 3 I I
PC 2 Amendment
Amendments - Cash Contributions, Loans Received and In-Kind Rcv.I2103
Candidate or Political Committee Name:
Write-In Jim Torrey
Election: 0 Primary 20_
Report: 0 I st Pre-election
Committee ID Number:
None Page 1 of 1
o Other_
o Post-election 200 r September Supplemental
o General 20_
o 2nd Pre-election
SEE BACK FOR INSTRUCTIONS AND CODE DEFINITIONS
CODE 1: Contributor Type
B Business Entity
C Political Committee (includes business and union PACs)
F Candidate's Innnediate Family (includes candidate)
I Individual
L Labor Organization
o Other
P Political Party Committee
Amending Page #
and Une #
Date Received
Page_line_
D New Entry
181 Correcting
o Deleting
5-10-05
Page_line_
D New Entry
181 Correcting
o Deleting
12-22-04
Page_ line_
D New Entry
o Correcting
D Deleting
Page_line_
D New Entry
o Correcting
o Deleting
Page_Line_
D New Entry
o Correcting
o Deleting
See
Instructions
on Back and
in Campaign
Finance
Manual
PC2
Amendment
Name and Address of Contributor
Amount of
Contribution
Contributor
Aggregate
Occupational Information or
Contributing Committee's ID#
Avon Lee Babb
645 Spyglass
Eugene, OR 97401
$
Sand/gravel business owner
$
J.H. Gonyea III
PO Box 269
Springfield, OR 974771
Lumber broker
CODE 2: Contribution Type
CA Cash
CO Cosigner Obligation
IK In-Kind
LR Loan Received
Code 1
Code 2
100.00
100.00
CA
$ 1,000.00
$ 2,000.00 CA
$
$
$
$
$
$
"Vh-~A.J:1C!<n lredwev
Signature of candidate or treasurer I
q/ :VJh-(
Datb signetl
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