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Commonwealth of Pennsylvania-Campaign Finance Report
(Note:This report must be clear and legible.It should be typed)
Filif identification Report iled By^t{ 'Candidate Q Committee�r Bibb ist '�'
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Number rz at ,, a^ ,,{Mark_ix) hr,� :^C..'!�".'�Mitis*,.�",. .: ....ih'. ' .`�a;.2r,i!'ky3`Y;>P �7,, ;�?. ;,Z;�i,*.
sName ofFiling ComFriittee,Candidate or ;L" `
' x� >. ','i n °jY�,�..riia 5y F A^ ,;-�4`'r'`i;JAIME M KEATING
•
L.ObbylSt,•c;1yr, `�,rwr.�'a.. , >;h.,r.; »k- nt f ";
Street Address vti Vt� tS' Yi '+krl S``"i'",[1*{t 4}4 •
F� ✓$x`3 0,n?$ 1 pti'%. ::"(m s`oazkoi ti,,.:»r; 529 BOSLER DRIVE . .
City ,, �vyn? cState�'. ,Zip C9de-0 17013
pt t CARLISLE Y PA is r y ' •
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Type of Report(Place x under report type)
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Prerprim,ary$ Pre riiiarBPriiiiiiy ,taPrElection :�;PreEleetYonElection °� 33^ Pre ,EostElection'
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Date"Of Election �r ��`� r a�� Year, r<�,w��� �: Amendment � [ ,Termination k,;�,��.
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(MINI/DD/n'rr) , { ,r A 11(c d(�I »,� a1 1 Repurie int ro. Report�sy�� i D
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Suiriinar. of�Recei isand'4 i Fram:Date ' `�tt �Tb Date,'l tiff� ,,�e "4r;i4`y� } `t For Office Use,,Oniyz PIRM. �x -^� ,`".'
r(%;�`.':.. ,�'7�r.� .+�a:p.. r�. S`v" �t a. „F� .c '���. i. r'3,`���"1;T3�r �?%'��uF'w%�n.C;�� T�k r�y�{. '�. s'r�S,�..,�,�.u�?'h S- ass�'wpL.�y� �«[,y:1 r�i'r'-*ii.. �' ��.;�+��kt��r��j
i i t. 1 'i. a a' a 0g,ida.tr„�.„- as rsc�.«;�.n ''f +�,:.,>'a;'+r 'r r �+k .f' '. t.yr roi'�;v - V” �,r� x h, c z�.'�.
�Expenditure`s � ,�, � t ��r n ,� .��� c� aM �a'���y�J �tc�rr�^��t� ��a ���. {�1 ��`��.*�-', .
'+'�`i,', ,cti�t >t� �.F �'�"' .�� 10/22/2019 11/18/2019 '*J�t �� rc•4'�+ � a�Cr> w�fJ~ s��'�:,r±�.�i � r,�c � ����s•s Q��.
r� 1 . n ,..ay;M xV x4.44' 4... •
loll fik` 'a I Y P n - A'F n t , 4.v rrii.`'.;'V�r. �i?.yxr, £.'
r �. a,d� �. a .�.m. �.r. x..d..F;�..�„�r�a.�..�:�.;�sts r�2?4a.
A=Amoiint,arought Forward From Last Report n, $ �^ "`—
i''s ,r' S}y k: . A,4r�Y ralk• & -. 4./.1- 44. -28,730.85 •�.c, .
tq th, at t fid, x .7',,Aa. <,.f n.' .h.r*rKR;fi t' lv C23 2r.
B`-Total Monetary Contributions ram Atetiiiitimv $
eT? O
Uey � _ 153
-
Y{FrOf1SChdl , 4td trc
2.0 Total�Funds Avai able''R�1,a ;, n, i J `f�'? $ • "b •UI
u w s e �..s Z f-}y S h 4�+4 `w of -28,577.85 Q Q
°(Sum of,Lines A,,andA6)z.trr`ti' tit{ tt4,.1� i., ,. •
it Total ESC endit ltie �;¢ay�t1 'S Y xr Vin l x. • =Z
( )rr3 C CO c2 `'
E Ending Ca• shhip,i•nce �Yr :l d.00: : $ -28,577.85 • +,y,^ Z ••1304
.
{Subtract tine Drfrom�tane t),:fia4,R rR xa '.i .. . :C)w . o
F'AValue of ins Kind Contributions Received x,, $ o- n Z �,
--,•,..,-.A.........,,.t > +r.4.%.4..4'43,.t'..42.40.4,-.4i0.4.'4,..1,3 ' T&,x t.'7�,i.'"."''''''.; 0 _ Lt. J
{From Sehr Ule U) ,, o i.z ,2 +. O
. xrst�` ', ,� F, sr 4L .
G Unpaid Debts and Obligations.i3 "o, el .$ - • -ice— Q 1 -
r''kr a n s„3ym w ar, tid," - ""' 0 J h
{F,rom Schedule lVJ4,•.z� ...: E )'*.t -ottto rn:.i{ `},
Affidavit Section '- Q
Part 1-If this is a Committee report,treasurer sign here.If this is a Candidate report,candidate sign here. •-
I swear(or affirm)that this report,including the attached schedules on paper,is to the best of my knowledge and belief true,correct and complete. i ' ,o
Q i 1
Sworn to and subscribed� before me this 0
/, # . dGP ay of ,t//4/- 20 9 • `
Signature of Person Submitting re..
, /_ JA KEATING II -
v+~ SignaturePrinted Name
•
My Commission expires O.S" ' c23 Jr�JQ 717 • 433-2332
MO. DAY YR. Area Code Daytime Telephone Number
Part II-If this is a report of a Candidate's Authorized Committee,candidate shall sign here.
I swear(or affirm)that to the best of my knowledge and belief 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
day of 20
• Signature of Candidate •
• Signature Printed Name
My Commission expires
• MO. DAY YR. . Area Code • Daytime Telephone Number
.
• SCHEDULE I •
' • Contributions and Receipts
Detailed Summary Page
xFlieryidentification Number 7,
1_Unrtemize l Conttibutioas and Receii ts-$50"00 or Less per Contributor,' * _ A f'�' Y s a; r ;"?*L '�,.�_��0 ,'',o? . 4;'°
T. x+s Y �.� M1vySr :W�. §�4'.-5 ;.::'{yp +;.- '�. 'Ch`zC• ii ...rusk -. ;jai 8.^..ty>!r?,=f✓� a y -}��Y Ci.j,i.•ws1�- }t�».t tk...,Y Y- � `r i�c`£..'4 �`
y-4.a,. :i �. 3 s, s !k•'/-d: t v -.,c t ,,x i. "i t> 7 -�" I'f x. Y „k ws. •d' st_i ` -t• F ';Tt`>G.a.w,Y 4 M. A-
I .r..ct,'`"_A`+.xs;,. u ,...,::.i. �•..aux, .::�..x.,_�;,...r.,.r#''n,ray r..,:�t..,�„ =+.p.; .a.l+�vr� "��t-r.IN.,3>r:,:.r,,.F.1. ' ?.k..,,fir.,-.. tea: „-•. `S'.wi. .-.;fi't,., v'`�`.xr,-±c.
Total for the reporting period (1) $ "
rt2;Conti•iktittion3 o,$50 01 to$2S0:0b EroEIMM R. �„ r y a�; r b a K-. z� ;, s,.`,, y 4 ,,t.ift ,, . .
r";r;,,„, a r. r y,h,�;. e { � •i z,4s ,rt7,�s..7 t.fix” w'r" ��4i-1 '3? t�ry .x �7 $�� "� 1�v
i:..R,;�, :Ra *�,� -.K,.Ytd s Y; t'`t,fs r -n,y„al rii, �4 JSkz' 0 k r , ti.i - '. 4<,rc ,y x e, f °$`
$; .� 1'14 x"�. �?n^i+3 1���M r t s .E3 ,�y .�.,�a •F• �P.fi x g�.�.�a}y'��t . ��,r,'.
:Part A end Part. - 4. j_,' o,s §,,,e.l Q1:...,t,f�`,A-,,f* .k=.. '}r; �v.�e,k,,,v F y 3 t -`rroi 4 r„ds`110 6,,,-"!°ad�.. `z w. 41i43:.'1
x. .. --o....a e-.,..R,.. X+' �. u.'«v- tk l a� ..e'+ u' x.X-T7-trs.:..s„.:,1'a,t+4.,�.:y-.� _ .N; +{.a F�t', ,r'?:
Contributions Received from Political Committees(Part A) $
All Other Contributions(Part B) $
Total for the reporting period (2) $
-
k., S--' _ _-�.-,r,� �...it a* ,r i'.--'7 .^�5.+,y,y...+SFS^,Y' "yrt ';5, - 4 �'sr.,:. ' �•i- SL'<'°�'- ¢ ;a.3:i^-- ✓vac•' •'
3..Contributions,Ovef$250 00{Ero OPart, and Part I)) rgfP a�,{,s',� _�> ,y,, „, ,�� ,, i ,. STA ,. 4 as ,mss, i S h g ,
g�.��tom,,:. r�''b 4t;.•'�' ',.w•�;.x1+. ✓- .Y:4``�'•1. �,} a��� '.,+�y'?i;�n ; •a��:, '�'14x.�nr,_ r�.*+t� �`' ? 4 �x'.�`�,4s�%r '�:� �"'��'^"' 4. � �.s•;,,�rfi.J'�:at�^.,x a1',cy t,�.L�,y ^c.;•'�!
4 'rc'n. r i -aw,.T. 4,,r vy L F`•,s .f V 1 VO3 ` ii kyr• ±S r 6 ,1L• - a ^Fa. _"yt O i'.'2,. 10-.�i'4''�'�.r ..t d n 1. r 1,0 4 �c�`t�Oin.'^
. n.,.: :'a^Zi..E ;., „�9W,r" �i ..h?:'e-? a.,..,"p.A.'.x. .,,V,. ?n.41, err"� i"., `1--, Pu:r.,1&,r rt-v4,4,1.':..'. ,..k• .,,,h.�- ":ltd,i1tg,r4t1?c,IJr.(`:Sk,t?Yh,k, .,,.:M,sr. ,,,,... t.Y_,t,,r„, ,Tt:,1.1,7 X..s.�.
Contributions Received from Political Committees(Part C) $
•
All Other Contributions(Part D) $ •
Total for the reporting period (3) $ •
- 91:Otherfteei tf`'ItefG"ndsjylnterest',ar`ned ReturnedChecks}77C.(from�PartE'" a' +afr gfea �s�' .� �7 rF t"M ;rxg�` a �'
" +srt,-a - p, F t;: �+'{�:., r ,�. 6". � A u,. � .r ti.v '°4.rS -+ .,�,a��4#,a,�:'r._¢�� �,, r a x 4� F�,.t T �,;,t x ""s-0 y" '�"Y.� r,,�'
'5.c ', - Xlv ,`... ,*2'v'Fa.tl- P -�"'Y t . ,�,a tE-kt',._,;,.i,'.! :yZ�,7,°.�;.�:p-A::vt., gf d:.,'Ye(.•p-"-''rr`l 5"':klt s],,, J�'�.as#sywr«e aF _,-AP*44.'ita "F$»",y'-v":
I 'F''g'`k'.,,,t4si: a '..'};u. '�.§: xYgS da,-A' .i5.t.i-,ri`.41",t�^r �*,rr_.,,,,:kil'V-,t r,,;4,1k'e x,00-.`a�r r,i3 ,..41 1,:6s+ut 3x.-1,,s•.C,.;:Ms,i,+o-C. x. .54.*:-' .'r,<ro.4,it Cx#'•k!ir Z,;A f K.,,,A$10.=::
Total for the reporting period (4) $
153
Total Monetary Contributions and Receipts during this reporting period(Add and $
enter amount totals from Boxes 1,2,3 and 4;also enter this amount on Page 1,Report
Cover Page,Item B) 153
•
•
•
•
•
to
PART A
Contributions Received 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.
Filer Identification Number
Amount
Full Name of Contributing Date[MM/DD/YYYYj. $
Committee ffovr
House# Street Address Date[MM/DD/YYYY] $
City: State Zip Code :Date[MINI/DD/YYYY. ] . $'
Full Name of Contributing Date[MM/DD/YYW] $.
Committee
House# Street Address Date[MM/DD/YYYYJ $
City State Zip Code` Date[MM/DD/YYYY]. $
Full Name of Contributing ;Date[MM/DD/YYYY] ' $
Committee
House# Street Address Date{MM/DD/YYYYI: $
City State Zip Code;; Date[MM/DD/YYYYJ $,,
Full Name of Contributing. Date(MM/DD/YYYY]_ $.
Committee
House# Street Address . Date[MM/DD/YYYY] $
City State . Zip Code . Date[MM/DD/YYYY] $
Full Name of Contributing Date[MM/DD/YYYY] $
Committee ..
House#` Street Address Date[MM/DD/YYYY] $
City State Zip Code Date[MM/DD/YYYY]°, : $
Full Name of Contributing Date{MM/DD/YYYY] ` $
Committee
House#. Street Address Date[MM/DD/YYYYJ-.":$
City State Zip Code :';. Date[MM/DD/YYYYj $
11
PART B
All Other Contributions
$50.01 TO$250
Use this Part to itemize all other contributions with an aggregate value from
$50.01 TO$250 in the reporting period.
(Exclude contributions from political committees reported in Part A.)
filer identification Number:;II
r'Date )VIAIRVI'MO" 51 Now
iFull.Name of Contributor. [MM/DD/YYY,Y)
4,„
fHouse.# StViet Addre`ss Date[MM/DD/,YYYY],A w
kgity;t !, ;iState1 IZip Code!rii Date;[MM/DD/Y1!YYIt,;l.$
iFull Name°of contributor" Date MM DD t
pHouseB Street-Address !,Date.[MM/DD/YYY,Y1T .-
L
y.
city`
'1‘4 State 'Ziq Code u iDatejMM/DD/YYYY) . $r
Foil Name:of Contributors; ;Date:[MM/Ut3/YYYY)!� $1
r r
tq
*haute#i' 4 s SiDate,[MM/DD/YYYY1 i I5
g, Street Atldres
City' IStatq
ZpCode
Y '.;Date[MM/D /Y,YYY141
F � 4X "0 ,
Ftill
Nameof Contributor ,.Date jMM/DD/YYYY1`f i:$
House# Street Address ','Date[MM/DD)YY.YY]y t
}.{ga .Aux.
,�Ctty3 Sel. 1Iip Codert r.Date[NIMJDD/m!Y1; s$t
q t" ?yt M rd 6 '4,rr,x4
1 Full Name'of Contributor r. 1Date.[MM/DD/YYYY/1 $#.
iHouse#) Street Address )Date:[MM/DD/YYYY1;k$"
e,t,14,41‘11,—: 'llv".,,,i,:- . ' ).4. ,,..
City '.:.State Zip Code f Date IMM/DO/YYYY1 1 $g
Full i+lamco •
e'of contributor. Date[MM/DD/YYYi i- ,4!
=Mat.
House#ri Street Address
!Pate
"Date AM
/DDYYY) E$
T apVy,-a, y
t �w�
.x U,. �
Ail-s q A.MC
(City ; :1State1 'tztpCodeZ „Date;[MM/DDIYYYY11 );ti
�r�", xa T, �..� "�^ms`s wK _ . 7
1.1 I 1a
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$250.00 in the reporting period.
}filar.identiifi{caf t�iio,�nNumbe(?,
I
I
;Full•NameN 1 4i, r , .it) te[MM/DD/YYY,Y]�
C_ontnbuting Cornmittee.:;
':i-Z6VIY: ..t%,,. glair
Mouse#4 StreetAddress 1Date'[MM,IDD/YYY,Y13r s;-
,f.i.t:Ittc4-ri.ii, 07,-,g,",;,-„sk
Cityr Statel pCode ' Mate[MM/DDJY,�.YYY] IP
I`
:fun Name'offv.,;Wo! .00e[MM/DD/YYYY
,Co' ntributln Committee F
House•# Street tDate•[MINI/DD/,YYYY3S z$s
el,,,,,,,,.: �} rt q
'State; pcade� ` Date IMM/DD/YYYY]i l$
!full Name'of',• .V {Date{MM/DD/YYYYI ;i$1
Contributing Committee"; "a
iHouse#, Street'Addtess ,':',Date LMM/DO/XYYyj $
KNOZ,' ,1
rtt
IV, 4709 4.v
km.L.:, ,,,,,--,‘ 1-1:''' ,-•i4'tt;'''r°''..s•!-iXt'4.u'lett
City f State,; tZip Code 1 tUate fIyIM/DD/y,YYY,I w t$1'
114
iFtiIf Narne of'`"+,W;$ , {Date[MM/DD/YYYY1;,f$[
rCvntrbu
, ting Committee p
>",,.nF }r'S • '+Vii'': Yi
House# e;Addre"ssLDate IMM/DD/YY,YY]' - $_;
'AIK,t,f.',.'gr, ,f,:r.•:yori• „fsit<it •
City L, t a qde. j ;Date[iVINI/DUJYYYYj;�
Lfull Nameofa'6 �"'�'k Af� ioate[MM/DD/YYYY)11 1,•: ':Contributing Committee , 44.Contributing
A
house#i Street Address : Date;[MM/DD/YYY,YJ '$
SPS4MTl. ` �`�� y.S„'4,
City;>.* LStatett `ZlpCode, : fiDate_'X.MM/DD,YY,Y.Y]�► f$
Ft
O.
full Name`of''• ?Date[MM Y'*f/OD/ i$y
1-'%-t. W spa
Contributing Committee:, .
•House# StreetAddress i.Date[JVIMJDD/YWY1 $�
icity YtateiipyCode,'"1 &Date[MM/DD/YYYY]g I$
9ti. i.tti
n4':Lk.t. , ,ia!' 1; iii
5 /ia
PART D
All Other Contributions
Over$250.00
Use this Part to itemize all other contributions with an aggregate value over$250.00 in the reporting period.
(Exclude contributions from political committees reported in Part C)
Filer identification Number:
Full Name of Contributor Date[MM/DD/YYYY] $
House# Street Address Date(MM/DD%YYYYJ
City State 1 Zip Code Date[MM/DD/YYYY] $
Employer Name • Occupation
Employer Mailing Address/
Principal Place of Business
Full Name of Contributor Date iNIM/DD/YYYY] $
House# Street Address Date[MM/DD/YYYY]
City State Zip.Code Date[MM/DD/YYYY] $
Employer Name " • Occupation
Employer Mailing Address/
Principal Plate of Business
Full Name of Contributor Date tMM/DD/YYYYJ $
House# Street Address Date IMM/DD/YYYYI: $
City .State Zip Code Date[MM/DD/YYYYJ, $
Employer Name Occupation
Employer Mailing Address/,
Principal Place of Business
Full Name of Contributor DatefMM/DD/YYYYJ $
House#. Street Address Date1'MM/DDiYYYYJ ,''$
City . State , Zip Code "' Date JMM/DD/YYYYJ $
Employer Name Occupation
Employer Mailing Address/
Principal Place Of Business - .:
bfia
•
PART E
Other Receipts
REFUNDS,INTREST INCOME,RETURNED CHECKS, ETC.
Use this Part to report refunds received,interest earned,returned checks and prior expenditures that were returned to the filer.
Fifer identification Number:
I
Full Name . CITIZENS FOR KEATING
House# Street Address
950 WALNUT BOTTOM ROAD,STE 15-153
City' State Zip.. 1 Date[MM/OD/YYYYJ $
CARLISLE PA Code 17013 153
11/18/2019
Receipt'Description BALANCE OF COMMITTEE BANK ACCOUNT;CLOSED THIS DATE. PARTIAL REPAYMENT OF CANDIDATE LOAN.
FullName' "
House#' Street Address
City State,. Zip :Date[MM/DD/YYYYJ $
Code
Receipt_Description,
Full Name
House`# Street Address
City .State ,Zip ; Date(MM/OD/YYYY] $
Code
Receipt Description
Full Name:. ..
House# Street Address
City State lip Date(MM/DD/Y erti. ,$
Code.`
Receipt Description
Rall Name.` .
House# Street Address
City State Zip Date[MM/DD./YYYYJ.: `$:
Code
Receipt Description
FullName.
House# Street Address
City State Zip, Date.[MM/i)D/YYYYI :'...$.,
Code.
Receipt Description
4.//a
SCHEDULE II
IN-KIND CONTRIBUTIONS AND VALUABLE THINGS RECIEVED
USE THIS SCHEDULE TO REPORT ALL IN-KIND CONTRIBUTIONS OF VALUABLE THINGS DURING THE REPORTING PERIOD
DETAILED SUMMARY PAGE
Filenidentificatiotl NO1t10er • I
1 'JNITl=11I11�ED 161 1(1611 CONT;R1gl3TION5 RECEIVVAWE OF$SO 00.OR-LESS PER CONTRi9UTOR
ED ^T
TOTAL for the reporting period (1) $
I `2 IN:KIND CONTRIBUTIONS RECEIVED VALUE OF;$50 01+T0$250;00(I=RON PART) I
TOTAL for the reporting period (2) $
I3 ,IN-(IND CONTRIBUTION REUIVED-VALU_ OVM$25{i.R30{FROM PART:G)
TOTAL for the reporting period (3) $
TOTAL VALUE OF IN-KIND CONTRIBUTIONS DURING THIS REPORTING $
PERIOD(Add and enter amount totals from boxes 1,2,and 3;also enter ivois(e--
on Page 1,Report Cover Page,Item F)
8ha
SCHEDULE II
PART F
In-Kind Contributions Received
VALUE OF$50.01 TO$250
filer Identification Number:
full Name of Contributor Date[MM/DD/YYYY]: $
gOtig
House**' Street Address Date[MM/DD/YYYYJ $
City State ' Zip Code Date[MM/DD/YYYY] $
Description of Contribution
Full Name of Contributor Date[MM/DD/YYYY] $
House# Street Address Date[MMJDD/YYYY] $
City State Zip Code Date[MM/DD/YYYVI $
Description of Contribution
Full Name of Contributor Date[MM/DD/YYYY] $
House# Street.Address Date[MM/i)D/VYVY] $
City , State Zip Code-. Date[MM/ODJYYYY1 '$
Description of Contribution.
Full Name of Contributor Date[MM/DDJYYYYI $
House# Street.Address` Date[MM/DD/YYYY] $
City 7 State. Zip Code Date[MM/DD/YYYY]. . $
Description of Contribution
full Name of Contributor Date EMM/DD/YYYY] $
House# Street Address Date EMM/DD/YYYY] $
City State Zip Code Date[MM/DD/YYYYi $
Description_of Contribution
Q/1a
SCHEDULE II
Part G
In-Kind Contributions Received
VALUE OVER$250
filer Identification Number.
•
full Name of.Contributor Date;[MM/DD/YYYY] -$
ttoIE
house.#" Street Address Date[MM/DD/YYYYJ ., :. $..,
City State 'Zap-Code. ;Date,{MM/DD/yYrYj - $
Employer Name Occupation
Employer Mailing Address/Principal Description
Place of Business
Contribution
Full Name of Contributor :Date[MM/DD/YYYYj $
House#- Street Address Date[MM/DD/YYYY3'. ,$'
City State ZipCode: Date.[MM/DD/YYYYj $
Employer Name Occupation
Employer Mailing Address/Principal Description -,
Place of Susifess of.
Contribution.
full Name of Contributor ' Date[MM/DD/YYYYj - $`
House# Street Address Date IMM/DD/YYYYj. $
City State ;'Zip Code':=; Date[MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address)Principal: Description
Place of Business of
_Contribution
,Full.Name of Contributor Date[MM/OD/YYYY3 $
House# Street Address Date[MM/ODJYYYY] $`
City State ZipCode . pate[MM/DD/YXYY] -f $
Employer Name Occupation
.Employer,Mailing Address/Principal Description'
Place of Business of
Contribution ,
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SCHEDULE III
Statement of Expenditures
filer Identifitatibn Number:
To Whom Paid Date[MM/DD/YYYYJ $ wax,
House# Street Address Description of Expenditure
City State Zip,
Code
To Whom Paid Date jMM/DD/YYYYJ $
House# Street Address Description of Expenditure
City • State Zip
Code
To Whom Paid • Date(MM/DD/YYYYJ $
House# Street Address Description of Expenditure
City State Zip:
Code
To Whom Paid Date[MM/DD/YYYY] $
House# Street Address Description of Expenditure
City State Zip
Code
To Whom Paid Date tMM/DD/YYYYJ .$
House# Street Address Description of Expenditure
Gty State Zip •
Code.
To Whom Paid Date[MM/DD/YYYYJ $
House# Street Address .Description of Expenditure..
City State Zip
Code
To Whom Paid Date[MM/DD/YYYY] $
House# Street.Address . Description of Expenditure
City State Zip
Code
To Whom Paid.' - Date IMM/DD/YYYYJ $
House Street Address Description of Expenditure
City State , Zip
Code
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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.
Filer identification Number:.
Name of Creditor Outstanding Balance of Debt
House# Street Address DATE.DEBT'INCURRED $
[MM/DD/YYYY] Wawa,/
City State Zip
Code
Description of Debt
Name of Creditor Outstandi Balance of Debt
House.# Street Address DATE DEBT INCURRED $
[MM/DDIYYYY]
City State Zip
Code
Description of Debt
Name of Creditor Outstanding Balance of ebt
House#- Street Address DATE DEBT INCURRED $
[MM/DD/YYYY]
City State Zip
Code
Description of.Debt
Name of Creditor Outstanding B nce of Debt
House# Street Address DATE DEBT INCURRED _ $
[MMIDD/YYYYj
City State Zip
Code
Description of Debt
Name of Creditor Outstanding Began of Debt
House# Street Address DATE DEBT INCURRED $
(MM/DD/YYYY]
City State Zip
Code
DescriptionofDebt
Name of Creditor Outstanding Bat ce of Debt
House# Street Address, DATE DEBT INCURRED .$
[MM/DD/XYYY]
City State Zip
Code'
Description of Debt
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