HomeMy WebLinkAboutPA Assoc. of Amb. Surgical Ctrs. - 2017 Annual Report COMMONWEALTH OF PENNSYLVANIA
CAMPAIGN FINANCE STATEMENT
File this in lieu of a full report only if aggregate receipts, expenditures, or
liabilities incurred each did not exceed $250.00 during the reporting period.
FILER IDENTIFICATION Ov 2007017 REPORT FILED , CANDIDATE I COMTTEE 2
MIX LOBBYIST 3
NUMBER ON BEHALF OF
NAME OF FRAC COMMITTEE,CANDIDATE OR LOBBYIST
Pennsylvania Association of Ambulatory Surgical Centers
STREET ADDRESS
423 North 21st Street, Suite 104, American Office Center
CITY STATE ZIP CODE
Camp Hill PA 17011 —
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) MO. DAY YEAR
1.
6THTUESDAY
PRE-PRIMARY FOR OFFICE USE ONLY
MO. i DAY YEAR MO. I DAY I YEAR Com'
2ND FRIDAY
2. DATES OF C~ _
REPORNGPRE-PRIMARY PER ODn 01 01 2017 TO 12 31 2017 ....a.
30 DAY 3' n1 CO
POST-PRIMARY r
CASH BALANCE AT END 5 0 0 . 0 0
6TH TUESDAY
4' OF REPORTING PERIOD: Q
PRE-ELECTION }�
TOTAL AMOUNT OF FILER'S
2ND fRloaY
5. OUTSTANDING DEBTS OR LIABILITIES ....
0AT THE END OF REPORTING PERIOD: $ Z
PRE-ELECTION - O
6. - C
30 DAY -
POST-ELECTION AMENDMENT YES NO X - .._
7.
ANNUAL X TERMINATION YES NO
REPORT REPORT? X
AFFIDAVIT SECTION
PART I-
If statement is filed on behalf of a Political Committee or Candidates's Committee,the Treasurer must sign here.
< If statement is filed on behalf of a Candidate,the Candidate must sign here.
z •_-Ifinent is filed on behalf of a Contributing Lobbyist,the Lobbyist must sign here.
TCI,Sn AR(OR AFFIRM)THAT THE AGGREGATE RECEIPTS OR DISBURSEMENTS OR LIABILITIES INCURRED DURING THE REPORTING PERIOD INDICATED ABOVE DID NOT
, CrD TWO HUNDRED AND FIFTY DOLLARS(S2550.00)AND THIS REPORT IS,TO THE BEST OF MY KNOWLEDGE AND BELIEF,TRUE,CORRECT AND COMPLETE.
z2a
yrzl(4 E SWORN TO AND SUBSCRIBED BEFORE ME THIS
La- V ai DAY OF ( iet/J(/!;�{'l� 20 �e� N SUBMITTING REPORT
2 0 aii
F- / �/►� F. Wilson Jackson, M.D.
Tx
3 0 • ED. 0 STA -' Slry' RE ! PRINTED NAME •
z Z y E E MY COMMISSION EXPIRES tJ� / �/ 21� 717 761-0930
`` °' 8 MO. DAY J YR. AREA CODE DAYTIME TELEPHONE NUMBER
mac °- 8
o tiW� �
0rARFII-
If statement is filed on behalf of a Candidate's Authorized Committee, Candidate must sign here.
I SWEAR(OR AFFIRM)THAT TO THE BEST OF MY KNOWLEDGE AND BEUEF THIS POLITICAL COMMITTEE HAS NOT VIOLATED ANY PROVISIONS OF THE ACT OF
JUNE 3, 1937(P.L. 1333,No.320)AS AMENDED.
SWORN TO AND SUBSCRIBED BEFORE ME THIS
SIGNATURE OF CANDIDATE
DAY OF 20_
PRINTED NAME
SIGNATURE
MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NUMBER
M0. DAY YR.
Department of State • Bureau of Commissions,Elections and Legislation
DSEB-503(12-99) 210 North Office Building • Harrisburg,PA 17120-0029 • (717)787-5280