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Home My WebLink AboutSmith for Mayor - 2017 Annual Report • Commonwealth of Pennsylvania PAGE 1 OF 2. CAMPAIGN FINANCE REPORT (COVER PAGE) (NOTE: This report must be clear and legible. It may be typed or printed in blue or black ink.) Filer Identification ► Report O. CANDIDATE', 1• COMMITTEE • LOBBYIST Number: Filed By: Name of Filing Committee, Candidate or Lobbyist: .5Plc:t11 For }'lacLor Street Address: 785 ou_»&j Cl t'eoad City l__C3-r„p 1--li CL State: ^� Zip Coder 7011 - TYPE OF '6TH TUESDAY : 1• 2ND-FRIDAY'y 2• Y:: 30 DA :,f ,,,f 3. AMENDMENTYES:; ;.NO REPORT ,•PRE-PRIMARY PREPRIMARY, :` <;4POST:PRIMARY,,: '1REPORT?, 6TH TUESDAY . 2ND;FRIDAY 5• 30 DAY s• TERMINATION . . (place X to 'PRE ELECTION PRE-ELECTION POST ELECTION `+ REPORT? YES YNO` the right of ANNUAL. YEAR FILING METHOD report type) 'REPORT 17 ( '.) CHECK ONE , PAPER DISKETTE Name of Office Sought by Candidate: DATE OF ELECTION District Office Party County ,,, Number Code Code Code ..1('(a ter' OF Camp J('(() PA 'MO.: DAY' . :YEAR', 11 07 21)r 7 STH D eZi Camp (SEE INSTRUCTIONS FOR CODES) ''''FOR OFFictr oSE ONLY MO: :DAY. YEAR...'' MO. ;DAY .. YEAR , Su Expenditures Receipts I I Z 2-01 7 To I Z 31 2017 r-..3and Expendidi tures from: q A. Amount Brought Forward From Last Report $ 93 9_52Om co B. Total Monetary Contributions and Receipts (From Schedule I) $ / Zq o 1----5: • ,;L3 r— fV C. Total Funds Available (Sum of Lines A and B) $ 2-ZZ, !J �' 2uD D. Total Expenditures (From Schedule III) $ 2 Z? C <..) E. Ending Cash Balance (Subtract Line D from Line C) $ Q• 42 C w i N , 1__1_ C17 F. Value of In—Kind Contributions Received (From Schedule II) $ Q• -< O G. Unpaid Debts and Obligations (From Schedule IV) $ 0 °2 , AFFIDAVIT SECTION .PART:l If ;this is.a.Committee;;report, treasurer..:sign.here I;f this is..a,Candidate report, candidate sign`-here. , I swear (or affirm) that this report, including the attached schedules, on paper or computer diskette, are to the best of my knowledge and belief true, correct and complete. Sworn to and subscribed before me this ;//, a9 day of do...l C EALTH QF PENkip• ` ANIA n� NU).RHI .ShAL Signature o` : son Submitting Report � Jennifer 6�&mi Notary Public r�a ( �( c A // i Sik-AX-1—(S.11 �rdrrr ry>� ,.,York Ceupty 2 l"c51 OJ o /_I /V 2C C(C S'grInv8mmission Expires March 142019 Printed Name My commission expires OBER.PENN�Y<ANIA ASS0,&(1 NOTARIES /17 '7`7 - 2P6l7/ MO. DAY YR. Area Code Daytime Telephone Number • PART:.II 4 f` this is a report.:ofaCa- ndidato `�uN➢u poWrrt qIe,Oc,LaIfne shall::"O here, "' 1 swear (or affirm) that to the best of my knowledge affttitRUf'-$@rilsegtiOlotaayuRlnbliee has not vi• died any provisi•.11 of the Act of June 3, 1937 (P.L. 1333, No. 320) as amended. Lower Swatara Twp.,Dauphin County Sworn to and subscribed before me this My Commission Expires Feb.12,2020 q r MEMBER.PENNSYLVANIAASS IATION OF NOTARIEES `/ .1/.' 07 ` day of VEi % 20 iii �, /1/` �Si nature of and' to (34.140 �! %/'/ ez Signature^� ` //y Printed Na(mee ,14.,,,_ My commission expires �3Qf (� &CS 02 // � J" , MO. DAY YR. Area Code aytime Telephone Number Department of State • Bureau of Commissions, Elections and Legislation 303 North Office Building • Harrisburg, PA 17120-0029 • (717) 787-5280 DSEB-502 (7-99) SCHEDULE I PAGE 2 OF CONTRIBUTIONS AND RECEIPTS Detailed Summary Page Name of Filing Committee or Candidate Reporting Period or— From ///28/2OI7To I2./ i/2Oi7 1. UNITEMIZED CONTRIBUTIONS AND RECEIPTS - $50.00. OR LESS PER CONTRIBUTOR TOTAL for the Reporting Period (1) I $ 0. °-9- 2. CONTRIBUTIONS $50.01.TO $250.00 (FROM PART A AND PART B) Contributions Received from Political Committees (Part A) $ Q 00 4 -r^ All Other Contributions (Part B) $ f 2_9 �S TOTAL for the Reporting Period (2) $ z9 . I5 3. CONTRIBUTIONS OVER $250.00 (FROM PART C AND PART D) Contributions Received from Political Committees (Part C) $ 0. CDS)- All 6All Other Contributions (Part D) $ O OO TOTAL for the Reporting Period (3) $ Q Oo 4: OTHER RECEIPTS .- REFUNDS, INTEREST EARNED, RETURNED CHECKS, ETC. (FROM PART E) TOTAL for the Reporting Period (4) $ Q 0-2 TOTAL MONETARY CONTRIBUTIONS AND RECEIPTS DURING j 5. THIS REPORTING PERIOD (add and enter amount totals from $ i Zq Boxes 1 , 2, 3 and 4; also enter this amount on Page 1 , Report J Cover Page, Item B.) DSEB-502 (7-991 PAGE 3 OF /2_, PART A CONTRIBUTIONS - CRECEIVED FROM POLITICAL COMMITTEES $50.01 TO $250.00 Use this Part to itemize only contributions received from political committees with an aggregate value from $50.01 to $250.00 in the reporting period. Name of Filing Committee or Candidate Reporting Period Smi.tt For- Pia c-t'or- From 11/ 3/20/7 To iit51/20/7 -s_J DATE AMOUNT Full Name of Contributing Committee *A•11110:'' ,:DAY-,. ,YEAR - $ Mailing Address 'M0.- , DAY. , YEAR $ City State Zip Code (Plus 4) ,, MO. ,' • DAY, $ Full Name of Contributing Committee MO24 -.DAY, • "YEAR-'; $ Mailing Address :-.MO',; ' DAY ;., ',YEAR ' $ City State Zip Code (Plus 4) 4,,M0.• ; " DAY YEAR — $ Full Name of Contributing Committee • .'MO. • DAY•= YEAR,. $ Mailing Address ' 'MO. DAY . $ City State Zip Code (Plus 4) -mO.,.. , .DAY . $ Full Name of Contributing Committee '.'','MO. ., DAY - YEAR $ ' Mailing Address $ City State Zip Code (Plus 4) MO., - DAY YEAR ''- — $ Full Name of Contributing Committee -MO.' DAY, ''YEAR Mailing Address ,,,, „„ -:MO.,,. -•-•DA.." •YEAR , $ $ City State Zip Code (Plus 4) ,,,,MO. ' - 'DAY`' 'YEAR . — $ Full Name of Contributing Committee ',MO. < oDAY'',: YEAR , $ Mailing Address ''MO.,• .,4 DAV ,•,,,,YEAR , $ City State Zip Code (Plus 4) :...,,MO:" - ',DAY, YEAR — $ Full Name of Contributing Committee 1--..zMO. •• ' DAY' YEAR $ Mailing Address ';':MO; ' :"DAY,' $ City State Zip Code (Plus 4) ,%M0. • ,,,DAY'.i.--YEAR'',•' — $ Full Name of Contributing Committee , FAO:, DAY $ Mai ling Address -.f.;MO :t - DAY $ City State Zip Code (Plus 4) -MO: • , DAY- ; YEAR — $ PAGE TOTALoo Enter Grand Total of Part A on Schedule I, Detailed Summary Page, Section 2. $ 0 --- DSEB-502 (7-99) PART B PAGE hil OF / L ALL OTHER CONTRIBUTIONS . . $50.01 TO $250.00 . .. Use this Part to itemize all other contributions with an aggregate value from $50.01 to $250.00 in the reporting period. (Exclude contributions from political committees reported in Part A.) Name of Filing Committee or Candidate1Reporting Period Syn --C--k_ t-- 1-4aor- From 11/2/2.0i7 To /431/20/7 DATE AMOUNT Full Name of Contributor . Debbe. 5(y)(-t-L DA ?EAR $ /zci. /6- Mailing Address ,.,,tECNIC).•.S:+1'.DAYN'i ...YEARCE 766e0_01.14L-erj 0/u_b Aad $ City sptA Zip/ 70Co1de/(Plus 4) ::::'•31/1-0.:';',,47DAY.:,'" ':'''YEAR:,,,.,:,s3tyip -/-6*(( _ z: $ MO Full Name of Contributor ,. 4',:,:ZDAYi..::,r'YEAR : $ • Mailing Address ItelaV,:?,: .:DA`t.:•':i..':.6,,YEAR - $ City State. Zip Code (Plus 4) NA:1910.; N':DAY ' stYEAR'', $ Full Name of Contributor .'!'.',!MO.,:,,::,: V1'.DAY-. '' YEAR'! $ Mailing Address '!:•:Jlit&F,t ',.t21:5-AY-A,-''',4 YE A f C'.:' $ City State Zip Code (Plus 4) :',1/1f.X,M-',;, CSAY:,..••o K,4YEAft,f _ $ Full Name of Contributor ,r1V10 .?,, ,., DAY:::l'E: ..,',.YEARJ.,]•4. $ Mailing Address '.11/10:'.1.,-.1'117AY, kiYEAR $ City State Zip Code (Plus 4) ;',.•,mix....,,..,.„,,mtiAy. ,...! ?EAR* — $ Full Name of Contributor .',..,.•Ancr-gr, 4. 1::)AY:.!.:: ,ITYEAFL:;,:' $ Mailing AddressMI:r : .',''''1.•1',DAY'''.' YEAR'.., .„ $ City State Zip Code (Plus 4) ..:: Mo. ', :?,:::',..DAY. ,•:Y,EAtk. — $ Full Name of Contributor •• IVICL•':. .,.•;DAYv,?:'YEAR $ , Mailing Address :.,!.• 11040it. ,,DAY. ',''.:'!'-,'YEAR: $ City State Zip Code (Plus 4) rlIVIC)::°,,,A'.:.DAY'''• — $ Full Name of Contributor :?';!,!.M0.::; ..:.DA,I.:•:7A $ Mailing Address r.'11:010.1.•;.1.:•:,41:1AV,i6 WEAR'• $ City State Zip Code (Plus 4) Ma.N..,f,,, DAY z:,:,.'.'c.:.YEAR,T, $ Full Name of Contributor 0440/1.0UP ;''..iDAY ; YEAR A. $ Mailing Address •ighol:OE:=:','t DAY;—:5 ,,,,.Y,EAR'i $ City State Zip Code (Plus 4) ' II DAY. — . $ IPAGE TOTAL tilD Enter Grand Total of Part B on Schedule I. Detailed Summary Page, Section 2. $ I Z . /5. • DSEI3502 (7-99) • PAGE 5 OF 12, PART C CONTRIBUTIONS RECEIVED FROM POLITICAL COMMITTEES OVER $250.00 Use this Part to itemize only contributions received from political committees with an aggregate value over $250.00 in the reporting period. Name of Filing (Committee or Candidate Reporting Period .y 3yy1L (�f'(_ r Pia-C4Or— From ii/7t23/2.0i7 To iZ/3//�i DATE AMOUNT Full Name of Contributing Committee MO. DAY YEAR $ Mailing Address MO. DAY • .YEAR . $ 'City State Zip Code (Plus 4) MO. DAY YEAR .. Full Name of Contributing Committee MO. DAY YEAR" $ Mailing Address MO. DAY YEAR City State Zip Code (Plus 4) MO, DAY YEAR I $ Full Name of Contributing Committee -MO. DAY YEAR.. $ Mailing Address MO.'" DAY YEAR $ City State Zip Code (Plus 4) MO. DAY YEAR — $ Full Name of Contributing Committee MO. DAY YEAR $ Mailing Address MO. DAY YEAR $ City State Zip Code (Plus 4) . MO. DAY YEAR Full Name of Contributing Committee MO. DAY YEAR $ Mailing Address MO. ,,.: DAY YEAR $ City State Zip Code (Plus 4) MO. DAY YEAR .. Full Name of Contributing Committee MO.• DAY YEAR $ Mailing Address MO. DAY YEAR City State Zip Code (Plus 4) MO. DAY • YEAR $ Full Name of Contributing Committee MO. DAY YEAR $ Mailing Address MO. DAY .: YEAR $ City State Zip Code (Plus 4) MO. .DAY .YEAR Full Name of Contributing Committee MO... . DAY _' YEAR $ Mailing Address MO. , DAY YEAR $ City State Zip Code (Plus 4) MO. -DAY. -YEAR PAGE TOTAL Enter Grand Total of Part C on Schedule 1,'Detailed Summary Page, Section 3. $ 0, DSEB-502 (7-99) • PART D PAGE 6 OF /2— . . ALL OTHER CONTRIBUTIONS OVER $250.00 Use this Part to itemize all other contributions with an aggregate value of over $250.00 in the reporting period. (Exclude contributions from political committees reported in Part C.) Name of Filing Committee or Candidate SrY1 Lt-k- For' .11C33 0 C Reporting Period From /1/7,812017 To a/3/0/7 DATE AMOUNT Full Name of Contributor •-.AVieS:.•:1--l', OAY':•:' -.YEAR:',' $ Mailing Address ;... Ago...,i.: .:,:bAy;,,..,. WEAR',',- , 40 City State Zip Code (Plus 4) 'gri/I'Ci".':,,I''!,7;•!".'DAY,',,Th 4 YEA1V1 $ Employer Name Occupation Employer Mailing Address/Principal Place of Business Full Name of Contributor •',A1/10:'.:.:: 411)AY.:; :;.,,,YEAR v4 $ Mailing Address 1140".;;=-n •':.DAY'''': !(,EAR''t^', $ City State Zip Code (Plus 4) '.,,Mre ., ',.',.4DAY!'1:?1YEAr);,:,,;, . $ Employer Name Occupation Employer Mailing Address/Principal Place of Business Full Name of Contributor *^MC1,,.., :-.--'1)AY!;::••:.,YEAR-.:•. $ Mailing Address :::.M0.! ",,,,::DAYn -<,:i.YEAR'";!, $ City State Zip Code (Plus 4) ':: iviD.'.'!.. NYiDAY ..• •':YEAR — $ Employer Name Occupation Employer Mailing Address/Principal Place of Business Full Name of Contributor • :•MO.';;: i'. .:DAst.,,.•. '. 4) Mailing Address ,', -.M(:)'.. .. DAY:II ,...,,.-YEAV.," ,.. . 41 City I State Zip Code (Plus 4) --, Ma:- !:,DAY - N'YEAFCr .. _ 40 Employer Name Occupation Employer Mailing Address/Principal Place of Business Full Name of Contributor 'MO.. :: DAY.'',-YEAR',, , ' 4) Mailing Address 40 City State Zip Code (Plus 4) MOV:::%.; DAY., : -mYEAR,:•...-Z ,.. _ 4) Employer Name Occupation Employer Mailing Address/Principal Place of Business 00 Enter Grand Total of Part D on Schedule I, Detailed Summary Page, Section 3. PAGEEAL $ DSEB-502 (7-99) PART E PAGE 7 OF /Z.. OTHER RECEIPTS REFUNDS, INTEREST INCOME, RETURNED CHECKS, ETC. Use this Part to report refunds received, interest earned, returned checks and prior expenditures that were returned to the filer. Name of Filing Committee or Candidate Reporting Period ...S al itk_ Rpr-- AS-Tr- From /1/78/7.0/7 To iz/3//20/7 Full Name Mailing Address City State Zip Code (Plus 4) ' wo.7 ..-',DAY1f"'YEAR '; Amount $ Receipt Description Full Name Mailing Address City State Zip Code (Plus 4) —,M0.' .:DAY":1 YEAR'IAmount _ $ Receipt Description Full Name Mailing Address City State Zip Code (Plus 4) z MO DAY Al YEAR," Amount $ • Receipt Description Full Name Mailing Address City State Zip Code (Plus 4) .;1110. '.' ,;DAY'2',. 'YEAR,,' Amount $ Receipt Description Full Name Mailing Address City State Zip Code (Plus 4) C<MO.; ',DAY',",'YEAR , Amount _ $ Receipt Description Full Name Mailing Address City State Zip Code (Plus 4) .MO. DAY -, YEARL- Amount $ Receipt Description IPAGE TOTAL Enter Grand Total of Part E on Schedule I, Detailed Summary Page, Section 4. $ C). ---- DSEB-502 (7-99) • SCHEDULE II PAGE 8 OF /?.....- , • IN-KIND CONTRIBUTIONS AND VALUABLE THINGS RECEIVED USE THIS SCHEDULE TO REPORT ALL IN-KIND CONTRIBUTIONS OF VALUABLE THINGS DURING THE REPORTING PERIOD. Detailed Summary Page Name of Filing Committee or CandidateanJReporting Period ,SmLfk hDr ✓ laJolr From 4746/20/7 To 12/5112017 1. `UNITEMIZED IN-KIND CONTRIBUTIONS RECEIVED - VALUE OF $50.00 OR LESS PER CONTRIBUTOR ' TOTAL for the Reporting Period (1) $ c o 2. IN-KIND CONTRIBUTIONS RECEIVED - VALUE OF $50.01 TO $250.00 (FROM PART F) TOTAL for the Reporting Period (2) I $ O U 3. ,IN-KIND CONTRIBUTION RECEIVED - VALUE OVER $250.00 (FROM PART G) TOTAL for the Reporting Period (3) $ 0.°4----) TOTAL VALUE OF IN-KIND CONTRIBUTIONS DURING THIS O REPORTING PERIOD (Add and enter amount totals from Boxes 1, 2, • $ 00 and 3; also enter on Page 1 , Report Cover Page, Item F.) DSEB-502 F-99) t • SCHEDULE II PAGE 9 OF /,2, PART F • IN-KIND CONTRIBUTIONS RECEIVED VALUE OF $50.01 TO $250.00 Name of Filing Committee or Candidate� � Reporting Period SMI l / l Ole J" l Or- From (1f f OI1 To 12-hI120/7 DATE AMOUNT Full Name of Contributor MO. DAY. ,.YEAR $ Mailing Address MO. . '''DAY YEAR $ City State Zip Code•IPlus 4) MO.' •DAY . YEAR $ Description of Contribution: Full Name of Contributor MO. DAY YEAR Mailing Address MO. DAY' YEAR $ City State Zip Code (Plus 4) ' MO. DAY YEAR. $ Description of Contribution: Full Name of Contributor MO. DAY YEAR $ Mailing AddressMO. DAY YEAR. City State Zip Code (Plus 4) MO. DAY.. YEAR $ Description of Contribution: Full Name of Contributor MO. •DAY YEAR $ Mailing Address MO: ' .'DAY.- YEAR $ City State Zip Code (Plus 4) MO.- DAY YEAR $ Description of Contribution: Full Name of Contributor MO. - DAY YEAR $ Mailing Address MO..' DAY YEAR $ City State Zip Code (Plus 4) MO.' DAY . YEAR $ Description of Contribution: Full Name of Contributor MO.r• DAY YEAR $ Mailing Address MO. :.DAY YEAR `, $ City State Zip Code (Plus 4) MO. .DAY-. YEAR $ Description of Contribution: PAGE TOTAL Enter Grand Total of Part F on Schedule II, In-Kind Contributions Detailed $ y0 00 Summary Page, Section 2. v DSEB-502 (7-99) SCHEDULE II . PAGE /0 OF /2_, PART G . .. IN-KIND CONTRIBUTIONS RECEIVED • VALUE OVER $250.00 Name of Filing Committee or Candidate Reporting Period 3rylLtk._ For' Ea-Ljor- From 11/7-81017 To 0-151/7,•0/7 I DATE AMOUNT Full Name of Contributor AM"." •,',13AY Mailing Address ;',MD.:•.; ::, .DAY.:'.-. .NEAR.n. $ City State Zip Code (Plus 4) :" ',MO.'', -MAY.` ,•YEAlt," _ $ Employer of Contributor Occupation Employer Mailing Address/Principal Place of Business Description of Contribution Full Name of Contributor '..:"M(1.:,:-R-:';DAY.,..,., ,YEAR.;, Mailing Address .... MO.'5:, . ?.'MAY., :YEAR, $ $ City State Zip Code (Plus 4) —,100. " ()AV.,' ,:,'.YEAR,'",, _ $ Employer of Contributor Occupation Employer Mailing Address/Principal Place of Business Description of Contribution . . Full Name of Contributor ., 1,110. ,,; .,..T,DAY,,,-!'YEAR. $ Mailing Address '•.4110... ;' :::,'DAY".. „YEAR $ City State Zip Code (Plus 4) .‘.;MO:',;:.'''..MAY--.,.7.YEAR,,.. $ Employer of Contributor Occupation Employer Mailing Address/Principal Place of Business Description of Contribution Full Name of Contributor f iivid.All ,,iii1::'.• $ Mailing Address - :ell.010. . t:•:'IdiA,le?-.•: "irtAft,3',' City State Zip Code (Plus 4) — $ Employer of Contributor Occupation • Employer Mailing Address/Principal Place of Business Description of Contribution Full Name of Contributor :':ilAO.'•,, :..DAY' :.:YEAR . $ Mailing Address ".•411:11,--,' '.1DAY : .;.'YEAR.: $ City State Zip Code (Plus 4) ' .-MQ...: ..1...DAY^!':;, ,-.YEAR,:;',. _ $ Employer of Contributor Occupation Employer Mailing Address/Principal Place of Business Description of Contribution PAGE TOTAL Enter Grand Total of Part G on Schedule II, In-Kind Contributions Detailed Summary Page, Section 3. $ 0 0 ° DSEB-502 (7-99) • PAGE // OF /2... SCHEDULE III • STATEMENT OF EXPENDITURES Name of Filing Committee or Candidate Reporting Period Fr-- )4ador- From 11/7,8/Z017 To /45//20/7 To WThriP7 iDdt,(Ie sti -4EAR'.;1Amount is 21)17 Mailing Address Description of Expenditure i7E3 atth-trj ?tab Roaci keimbors•e_me,Lt oppajnAt&t- CityState Zip Code (Plus 4) c13 /-6:a M /TM— -ft, Haas "Pr-eii-te To Whom Paid MO DAY ,1YEAR Amount P $ Mailing Address Description of Expenditure City State Zip Code (Plus 4) To Whom Paid PTD**: •,--VEAR;Al Amount $ Mailing Address Description of Expenditure City State Zip Code (Plus 4) To Whom Paid '::YEAFt'.':j Amount Mailing Address Description of Expenditure City State Zip Code (Plus 4) To Whom Paid •41,AY ';12YEAR 1 Amount $ Mailing Address Description of Expenditure City State Zip Code (Plus 4) To Whom Paid '5100. %4*AbAYi ';«YEAR'i,,,I Amount Mailing Address Description of Expenditure City State Zip Code (Plus 4) To Whom Paid 'YEAR "Amount $ Mailing Address Description of Expenditure City State Zip Code (Plus 4) To Whom Paid DAY ::.,scE.Azi Amount Mailing Address Description of Expenditure City State Zip Code (Plus 4) PAGE TOTAL Enter Grand Total of Expenditures on Page 1, Report Cover Page, Item D. $ 222 DSEB-502 (7-99) 0' PAGE /2, OF /z, SCHEDULE IV `` STATEMENT OF UNPAID DEBTS Use this Section to itemize all unpaid debts and obligations which are outstanding at the end of the reporting period. Name of Filing Committee or Candidate c Reporting Period �YY1 tGt, Fpr—�' J„I c�(.�©(-- From UU/742017 To 1215// 17 Name of Creditor 'Outstanding Balance of Debt Mailing Address DATE Mi DAY "i-„YEAR. ': $ gninkagniattRiNgfiniMMO DEBT INCURRED City State Zip Code (Plus 4) peennanginVaiMumansgon Description of Debt Name of Creditor Outstanding Balance of Debt $ Mailing Address DATE IMMOIM Mg0A--xili:;:ligYEAR DEBT INCURRED City - State Zip Code (Plus 4) Description of Debt Name of Creditor 'Outstanding Balance of Debt Mailing Address DATE MO ;:;DAY YARE .i $ giiinantaNijanigNERNIfiagg DEBT INCURRED City State Zip Code (Plus 4) Description of Debt Name of Creditor 'Outstanding Balance of Debt Mailing Address DATE MO DAY YEAR $ niNINMERROgginliNORP DEBT INCURRED City State Zip Code (Plus 4) MMURNIMMOIMINgiManneggMDescription of Debt Name of CreditorOutstanding Balance of Debt Mailing Address DATE O MDAY YEAR $ MINNOSNEMEMMINEM DEBT INCURRED City State Zip Code (Plus 4) Description of Debt Name of Creditor 'Outstanding Balance of Debt Mailing Address DATE MODAY :YEAR•,: $ DEBT INCURRED City State Zip Code (Plus 4) Description of Debt PAGE TOTAL Enter Grand Total of Unpaid Debts on Page 1, Report Cover Page, Item G. $ 0. of DSEB=502 (7-99)