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Home My WebLink AboutFriends of Judge Jessica Brewbaker - 2015 30-Day Post-Primary IW(�AIR� 7 I Reset Form Print Form 15u�]17 Commonwealth of Pennsylvania -Campaign Finance Report (Note:This report must be clear and legible. R should be typed) Filer Identification Report Filed By Candidate Committee I Lobbyist 17 Number 1 20150017 (Mark K) n Name of Filing Committee,Candidate or Lobbyist Friends of Judge Jessica Rrewbaker Street Address PO Box 444 City Carlisle State PA by Com...: 17013 Type of Report(Place x under report type) 1-bei Tuesday 2- 2nd Friday 3-30 Day Post 4-6e,Tuesday s-2 d Friday 6-30 Day Post 7-Annual Special 2 Friday Special 30 Day Pre-Primary .Pre-Primary Primary Pre-Election Pre-Election Election Pre-Election Post-Election E rX_1 El 1:1 1:1 El Date Of Election Year Amendment Termination (MM/DD/YYYY) 5/19/2015 2015 Report Report ❑ Summary of Receipts and From Date To Date For Office Use Only Expenditures 5/4/2015 6/8/2015 A.Amount Brought Forward From Last Report. $ 12 67768 B.Total Monetary Contributions and Receipts $ 26,07S "a (From Schedule 1) '? C.Total Funds Available (Sum of Lines A and B) 38,752.68 D.Total Expenditures $ �, (From Schedule 111) 38595.27 C.,1 E.Ending Cash Balance $ (Subtract tine D from Line C) 157.41 - - F.Value of In-Kind Contributions Received $ i (From Schedule 11) 1,171.41 G.Unpaid Debts and Obligations (From Schedule IV) 20'900 Affidavit Section 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,u to the best of my knowledge and belief true,cq ect and complete. Sworn to and subscribed before me this f q day of —r>'l l_ 20A IJ M,—Orf eo S tj"ZJ' rt� n� Si ture Printed Nacme { r My Commission expires OGS / Ob / zAi7 ^7 r -4-Ye—e57 c7 MO. DAYCOMMONWEALTH OF PENNSYLVANIJ _Code Daytime Telephone Number PartIF If this is a report of a Candidate's n ' 'gn#e. 1 swear(or affirm)that to the best of my k wledf� E®Bft[ee as net violated any provisions of the Act of lune 3,1937(P.L 1333,N0.320)as amended. My Commission Expires lune 6, 2017 FIEDIaER,PENNSYLVANIA ASSOCIAl10N OF NOTARtE Sworn to and subscribed before me this a i day of �l✓ne 20 1) � L L Si of ndidate Si ature Printed Name ^T My Commission expires O(n ( Ofr. �l TZ I 1 1 L4 1- L� MO. DAY YR. Area Code Daytime Telephone Number COMMONWEALTH OF PENNSYLVANIA Notarial Seal James M. Robinson, Notary Public Carlisle euro, Cumberland County My Commission Expires June 6, 2017 MEMBER,PENNSYLVANIA ASSOCIATION Of NOTARIES f SCHEDULE Contributions and Receipts Detailed Summary Page Filer Identification Number 20150017 1.Unitemized Contributions and Receipts-$50.00 or Less per Contributor Total for the reporting period (1) $ 375 ?-Contributions .0 to $250.00(From Part A and Part B) Contributions Received from Political Committees(Part A) $ 200 All Other Contributions(Part B) $ 2,450 Total for the reporting period (2) $ 2,650 3.Contributions over$250.00(From PartC and Part D) Contributions Received from Political Committees(Part C) $ 1,000 All Other Contributions(Part D) $ 22,050 Total for the reporting period (3) $ 23,050 4.Other Receipts-Refunds,Interest Earned,Returned Checks,ETC.(From Part E) Total for the reporting period (4) $ 0 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) 26,075 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 20150017 Amount Full Name of Contributing Date[MM/DD/YYYY] $ Committee Better Government For PA 200 5/18/2015 House# Street Address Date[MM/DD/YYYY] $ 813 Chambers St City State Zip Coda Date[MM/DD/YYYY[ $ Bressler PA 17113 Full Name of Contributing Date[MM/DD/YYYY] $ Committee Hou",* ouse# Street Address Date(MM/DO/YYYy[ $ City State Zip Code Date[MM/DD/YYYY] $ Full Name of Contributing Date[MM/DD/YYYY] $ Committee Le# Street Address Date[MM/DD/YYYY]State Zip Code Date[MM/DD/YYYY] $ Full Name of Contributing Date[MM/DD/RYYY] $ Committee House# Street Address Date[MM/DD/YYYY] S City State Tip Code Date(MM/DD/YYYYJ. S Full Name of Contributing Date[MM/DD/YYYY] $ Committee House# Street Address Daft[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] S 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. 0150017 Full Name of Contributor Date[MM/DD/YYYYI $ Patricia Clawges 4/18/2015 200 House# Street Address Date[MM/DD/YYYYI $ 2205 Fenwick Ave city State Zip Code Daft[MM/DD/YYYYI $ Mechanicsburg PA 17055 Full Name of Contributor Date IMM/DD/YYYYI $ Renee C Matter Myers 4/23/2015 100 HouseLE Street Address Date[MM/DD/YYYYI $ 5 Longwood Lane -- City State Zip code Date[MM/DD/YYYYI $ PA 17025 Full Name ofContributor Date[MM/DD/YYYYI $ Costopoulos,Foster&Fields 4/23/2015 250 House# Street AddDate[MM/DD/YPYYI $ I:M:.,k.t:Sl: 831 ' city State Zip Code Date[MM/DD/YYYYI Lemoyne PA 17043 Full Name of Contributor Date[MM/DD/YYYYI $ William Miller,Jr 4/23/2015 100 House# Street Address Date[MM/DD/YYYYI $ 1962 Chestnut St city 27p code Date[MM/DDf"W1 state $ Camp Hill PA 17011 Full Name of Contributor Daft[MM/DD/YYYYI $ Michael Sienkrewi¢ 250 4/24/2015 House# Street Address Date[MM/DD/YYYYI $ 320 Parker8t cityState Zip Code Date IMM/DD/YYYYI $ Carlisle PA 17013 Full Name of Contributor Date[MM/DD/YYYYI $ William Kronenberg 250 4/28/2015 House# Street Address Date[MM/DD/YYYYI $ 605 Devonshire Dr City State Zip Coda Date[MM/DD/YYYY] $ Carlisle PA 17013 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 IdentlBcatioe Number: 20150017 Full Name of Contributor Date[MM/DD/YYYYj $ William Hooke 4/27/2015 100 House# Street Address Date[MM/DD/YYYY] 322 South Hanover St city --...._-.. State 'P' Date[MM/DD/YYYY} ... $. Carlisle PA 17013 Full Name of Contributor Date[MM/DD/YYYYj $ Timothy McMahon 5/1/2015 100 12Ha Street Address Date[MM/0D/YYYYj $ 4456 Dunmore Dr State. .Zip Code. . Date-[MM/0D/YYYYI' $ rrisburg rgPA _ 17112 Full Name of Contributor I Dam.[MM/DD/Y" $ Shari Bellish 5/2/2015 100 House# Street Address Date.[MYYY M/DD(Y ] $. 59 Beagle Club Road City -.State Zip Code Date[MM D j Carlisle PA 17013 Full Name of Contributor Date[MM/DD/YYYYj $ George Costopoulos 5/8/2015 100 House# Street Address Date[MM/0D/YYYYj $ 153 IN Hanover St City State Zip Code. . 'Date[MM/UD/YYYYj _.S Carlisle PA 17013 Full Name of Contributor Daft(MM/DD/YyYy] Jonathan Silcox 100 5/9(2015 House# Street Address - Date[MM/DD/YYYYj $ 86 A Beard Road City State Zip Code Dam[MM/D0/YYYYj Enola - PA _ 17025 Full Name of Contributor Date[MM/DD/YYYYj $ Patricia Nixon 5/9/2015 100 House# Street Address Date[MM/DD/YYYY]. $ 304 Reservoir Rd City -State Zip Code Dam[MM D Mechanicsburg PA 17055 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. 0150017 Full Name of Contributor Date[MM/DD/YYYY) $ Bryan McQuillan 5/14/2015 150 House# Street Address Date[MM/DD/YM] $ 1114 Countryside Dr city - .State Zip Code Date[MIYt/DD/YYYY] - $ Harrisburg PA 17110 Full Name of Contributor Date(MM/DD/YM] $ Lawrence Barone 5/20/2015 100 E Street Address Dale(MM/DD/YYYY] 58 Nelson Or State Zip Code Date[MM/DD/YYYY]rlisle PA 17015 Full Name of Contributor Date[MM/DD/YYYY] $ David Rommel 5/9/2015 100 House It Street Address Date.(MM/DD/YYYYj $ 2324 Abbey Lane City State -Zip Code Date[MM/DD/ Y] Harrisburg PA 1]112 YYY Full Name of Contributor Date(MM/DD/YYYY] $ Frederick Huganir 5/14/2015 250 House# Street Address Date[MM/DD/YYYYj $ 221 � N Old Stonehouse Rd City State Zip Code Date[MM/DD/YYYY1 $ Carlisle PA 17015 Full Name of Contributor Date(MM/DD/YYYYj $ Elizabeth Zampogna 100 4/13/2015 I ouse# Street AddressDate(MM/DD/YYYY1 $ 710 Vista DrityState Zip Code Date(MM/DD/YYYY] $ Camp Hill PA 17011 Full Name of Contributor Date[MM/DD/YYYY1 $ House# SUreet Address Date(NIM/DD/YYYYj $ City State Zip Code -Date[MM D/YYYY1 $ 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. Filer Identifitatien Number: 0150017 Full Name of Date(MM/DD/YYYY] $ Contributing Committee PSEA PACE 5/7/2015 500 :House# I Street Addre Date[MM/DD/YYYYI $ 00 N Third St PO BOX 1724 city State 'P' - Date(MM/DD/YYYY[ $ Harrisburg PA 17105 Full Name of Date IMM/DD/YYYY] $ Contributing Committee Glen Grell For House Committee 5/20/2015 500 I ouse# StreetAddress Daft IMM/DD/YYYY] $ PO Boz 217iry State 'P' Date[MM/DD/YYYYI Camp Hill - PA 17011 Full Name of Date[MM/DD/MY] $ Contributing Committee House# Street Address Date IMM/DD/YYYY] $ Chy State Zip Code Date(MM/DD/YYYYI $ Full Name of Date[MM/DD/YYYY] $ Contributing Committee House# Street Address Date[MM/DD/YYYY[ $ city state Zip code Daft[MM/DD/WWI $ Full Name of Date[MM/DD/YYYY] $ Contributing Committee House# Street Address Date[MM/DD/Y" $ cHr state IIP code Date[MM/DD/YYYYI $ Full Name of Daft[MM/DD/YYYYI Contributing Committee Nouse# Sueet Address Date(MM/DD/YM] $ City State Zip Code Date[MM/DD/YYYY] PART D All Other Contributions Over$250.00 Use this Part to itemize all other contributions with an aggregate value over$250.00 in the reporting period. (Exclude contributions from political committees reported in Part C( Filer Iderrtnicatfon Number: 20150017 Fun Name of contributor. Date[MAWD/YYYYI: ,.:.$ Loan from Jessica Brewbaker 10,700 5/5/2015 House# street Address Date(MM/DD/YYYYI $: 815 Wellington Dr5,200 s/11/zols city state LP Code : Dam[MM/DD/YYYYI. $ Carlisle - PA 17013 Employer Name PAJudiciary Occupatioe. Magisterial Districtludge Employer Mailing Address/ Principal Place of Business 18 N Hanover Street,Carlisle PA 17013 Full Name.of Contributor.. Date[MM/DD/YYYYI - -$ Robert Becker350 5/6(2015 House# treetAddress .Date EMM/DD/YYYYI S 447 Graystone Court citystate Zip Code :Date[MM/DD/YYYYI $ Palmyra PA 17078 Employer Name Occupation Verizon Wireless Business Manager Employer Mailing Address/ Principal Place of Business : 20 Independence Blvd,Warren NJ 07059 Full Name of Contributor Date[MM/DD/YYYYI. : $ Loan from Dorothy Becker 5/11/2015 5,000 House# street Address Date[MM/DD/YYYYI '$ 48 Derbyshire Dr .City state Zip Code Date EMM D I , Carlisle PA 17015 Employer Name - .Occupation PSEA Assistan[to the Governance Employer Mainng Address/ Principal Place of Business 0 N 3rd Scree[Harrisburg PA 17105 Full Name of Contributor Date.[MM/DD/YYYYI.: :. $. Ronald Katzman500 5/11/2015 House# traeYAddress ,Date.(MM/DD/YYYYI 3600 Logan Ct,unit 6A City state Zip Code Date.(MM/DD/r" $ Camp Hill IPA 17011 Employer Name Goldburg Katzman Otwpatbn . Lawyer Employer Mailing Address/ Principal Place of Business'- . 4250 Crum Mills Rd,Harrisburg PA 17112 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. 0150017 Full Name of Contributor Date[MM/DD/YYYY] S Michael Bangs 4/15/2015 00 House# Street Address Date[MM/DD/YM] $ 429 5 18th 5 City. - State Zip Code Date[MM/OD/YYYY]. .. Camp Hill PA 17011 Employer Name Bangs law Office Occupation Lawyer Employer Mailing Address/ 429 5 18th St,Camp Hill PA 17011 Principal Place of Business Full Name of Contributor Date[MM/DD/YYYY] $ House It IStreetAddren ' Date[MM/DD/YYYY] $. City State 21p Code Date(MM/DD/YYYY] - $ Employer Name Occupation Employer Mailing Address/ Principal Place of Business Full Name of Contributor Date[MM/DD/YYYY] $ House# Street Address Date[MM/DD/YYYY] $ City State .Zip Code Date[MM/DD/YYYY] Employer Name occupation Employer Mailing Address/ Principal Place of Business Full Name of Contributor Date]MM/DD/YYYY] $ House# Street Address Date[MM/DD/YM] $ City State Yip Code Daft[MM/D¢/YYYY] - S Employer Name - Occupation Employer Mailing Address/ Principal Place of Business 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 Filer Identificatiort Number 20150017 1. UNITEMR€D IN-KIND CONTRIBUDONS RECENED-VALUE OF$50.00 OR LESS PER CONTRIBUTOR. - TOTAL for the reporting period (1) $ 71.95 2.. . IN-KIND CONTRIBUTIONS RECEIVED-VALUE OF$50.01T0.$250.00.(FROM PART F) TOTAL for the reporting period (2) 1 $ 259.46 3. IN-KIND CONTRIBUTION RECEIVED-VALUE OVER$250.00(FROM PART G) - TOTAL for the reporting period (3) $ 940 TOTAL VALUE OF IN-KIND CONTRIBUTIONS DURING THIS REPORTING $ PERIOD(Add and enter amount totals from boxes 1,2,and 3;also enter on Page 1,Report Cover Page,Item F) 1,171.41 SCHEDULE If PART F In-Kind Contributions Received VALUE OF$50.01 TO$250 Filer Identification Number: 0150017 Full Name of Contributor Date[MM/DD/YYYYj S Stacy Gromfich 4/29/2015 170 P93.4'. Street Address Date[MM/DD/YYYY] $ Hummel Avep Code Date[MM/DD/YYYY]e PA 11043 Description of Contribution tamps Full Name of ContributorDate[MM/DD/YYYYj $ Jessica Brewbaker 5/14/2015 9A6 House# .Street Address Date[MM/DD/YYYY] S 815 Wellington Dr City state Tip Code Date[MM/DD/YYYY] S Carlile PA 17013 Description of Contribution Stamps Full Name of Contributor Date]MM/DD/YYYYj $ House# Street Address Date[MM/DD/YYYY] $ City state Lp Code Date[MM/DD/YYYYj $ Description of Contribution Full Name of Contributor Date[MM/DD/YYYY] $ House It Street Address Date(MM/DD/YYYY] city State Zip.Code Date(MM/DD/YYYYj $ Description of Contribution Full Name of Contributor Date(MM/DD/MY] $ House It IStreet Address Date(MM/OD(YYYY]. City State Zip Code Date(MM/DD/YYYY] $ Description of Contribution SCHEDULE If Part G In-Kind Contributions Received VALUE OVER$250 Filer Identification Number. 20150017 Full Name of Contributor Date[MM/DD/YYYY] $ Mike Adler 5/11/2015 500 House# 291 City Street Address Date(MM/DD/YYYYI $, 5 Enols Rd Sate lip Code Date[MM/DD/YYYY] Carlisle PA 17073 Employer Name Occupation - - Sterling Property Management Owner Employer Mailing Address/Principal Description ff Place of Business 337 Lincoln St,Carlisle PA 17013 at Food for Fundraiser Contribution Full Name of Contributor Date[MM/DD/YYYY] $ iBany Mutzabaugh 5/13/2015 340 House# Street Address Date[MM/DD/YYYYI -$. 934 Hummel Ave cty I — state zip coati Dam[MM/DD/YYYYj 5 lemayne PA 17043 Employer Name Hazen Elder Law Occupation Legal Assistant Employer Mailing Address/Principal Description Place of Business 2000 Linglestown Rd,Harrisburg PA 17110 of Stamps,Paper and Envelopes Contribution Full Name of Contributor Date(MM/DD/YYYY] $ House# Street Address Date[MM/DD/YYYYI City State Zip Code Date[MM/DD/YYYYj $ Employer Name Occupation Employer Mailing Address/Principal Description Place of Business of Contribution Full Name of Contributor Date[MM/DD/YYYYj $ _— Date IMM/DD/YYYY] $ House# (Street Address city -_ state zip Code Daft[MM/DD/YYYY] $ Employer Name Occupation Employer Mailing Address/Principal Description Place of Business of Contribution SCHEDULE 111 Statement of Expenditures Fiter identfilcatfoa-Number. 20150017 TO.Whom Paid. Date[MM /YYYY] $ Hemlock Strategies S/5/2015 2,231.51 Street Address PO Box 7365 D � Nouse# City Steelton State.. PA �e 17113 rrvitation print and mail costs To Whom Paid $:Date[MM/DD/YYYY]: .. LN Consulting LLC 708 : - 5/5/2015 House#',121 SBeet Addressl State St Description of Experdflure city Harrisburg State. PA Code 17101 Post Cards To Whom Paid Date[MM/DD [ essica erewbaker 5/5/2015 1407.1 House#. . StreatAddress 815 Wellington Dr Description of Expenditure - State Co Reimbursement for Stamps and Office Supplies city Carlisle PA ;:Cede 17013 PP To Whom Paid Date[MM/DD/YYYY] $. LN Consulting LLC 5/5/201S 8,477.62 House Al 121 Street Address State St Description of Expenditure ZIP City Harrisburg State..- PA ,ode 17101 Mailing To Whom Paid Dab[MM/DD/YM] -1 $ LN Consulting LLC 5/5/2015 2,500 House#1 121 State St Street Address Description of Expenditure - Harrisburg state.:. PA zip17101 Signs To Whom Paid. Date[MM/DD/YYYY] $ Santander Bank - 35 5/7/2015 House#1 129 Streat.Addreu Description of Expenditure . -. SPitt St CitiCarlisle Stam. PA -i, --.'17013 Fee To Whom Paid Daft[MM/DD/YYYY] Santander Bank 5/8/2015 35 Houseq 129 Street Address S Pitt St Description of Expenditure - city Carlisle State PA zed, 17013 Fee To Whom Paid Daft(MM/DD/YYYY[:: Pay Pal 1.03 5/9/2015 House#I...1 Street Address North Firs[S[ Description of Expenditure -: LL I State CAC�e 5131 Pay Pal Fee - SCHEDULE 111 Statement of Expenditures Filer Identtlicadon Number. 20150017 T6.Whom Paid Date(MM[DD/YYTYj>: $. Jessica Brewbaker 5/12/2015 6,132.55 House# 815 Straat Addrossl Wellington Dr Descillpfflon of Expwwtllre CityCarlisle State-.<PA "P '17013 Reimbursement for Stamps and Office Supplies de I To Whom.Paid Daft jfAM/DD/YYYYj $ LN Consulting LLC 15,330.48 5/14/2015 House# Street Address Description of Expenditure 121 State St i City Harrisburg I State" PA Code `.17101 Mailings To Whom Paid :Date:(MM/DDAYM Pay Pal 5/14/2015 .65 .House# 2211 Street Address North First St D®SHiptiots Ot Expenditure zip l STite Pay Pal Fee San lose CA Code :.95131 To Whom Paid Date(MM/DD/YYYY}:. .: Pay Pal 5/20/2015 3.2 House# Street Address North First S[ Description of Expenditure 2211 City San lose State l CA Co de 5131 Pay Pal Fee Code To Whom Paid Date(MM/DD/YYYYj -$ 2211 Pay Pal essNorth First St 6/1/2015 1.75 Nouse# Street AddrDescription of Expenditure. City State t San lose CA CC4/ 95131 Pay Pal Fee To Whom Paid -Date(MM/DD/YYYYj` -$; LN Consulting LLC 2,727.38 6/4/2015 House# 121 State St Street Address Description of Expenditure - City I State: Zip Palm Cards,Post Cards and Auto Call Harrisburg PA ,CoQ. : 17101 To Whom Paid Daft IMM/DO/YYYYj., House If Street Address Description of Expenditure City State ZCoip de To Whom Paid-- Dari(MM/DD/YYYY(". House# Street Address Description of Expenditure City .State Zip Code 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. 20150017 Name of Creditor essica Brewbaker Outstanding Balance of Debt House# 'Street Address DATE.DEBT INCURRED $ . . _ 815 Wellington Or [MM/DD/YYYY[. 5/5/2015 CIYy Carlisle State PA Zip17013 10,700 Code Description of Debt Loan Name of Creditor Jessica Brewbaker Outstanding Balance of Debt House# IStreet Address DATE DEBT INCURRED $ 815 Wellington Or [MM/DD/YM[ 5/11/2015 city Carlisle State PA I Zipde 17013 5,200 1 co Description of Debt Loan Name of Creditor Dorothy Becker Outstanding Balance of Debt House# [Street Adder DATE DEBT INCURRED $ 48 IMM/DD/YYYY[ Derbyshire Or i5/5/2015 city Carlisle state PA Zip 17015 5.000 Description of Debt Loan Name of Creditor Outstanding Balance of Debt [,.:7 Street Address DATE DEBT INCURRED $ [MM/DD/YYYY[ _._ State LP Code Description of Debt Name of Creditor Outstanding Balance of Debt rE Street Address DATE DEBT INCURRED S [MM/OD/YYYYj City state I zip Code Description of Debt Name of Creditor Outstanding Balance of Debt House# street Address DATE DEBT INCURRED. $ IMM/DD/YYYY]. City state lip, Code Description of Debt