HomeMy WebLinkAboutPA Association of Ambulatory Surgical Centers - 2015 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.
FILM
NUP,t ID NTIFICATKIN � 2007017 ORN�BE ALF , CANDIDATE i. COMMIT'fE£ 3. 3.
X LOBBYIST
NAME OF HUNG COMMMEE,CANDIDATE OR LOBBYIST
Pennsylvania Association of Ambulatory Surgical Centers
STREET ADDRESS
423 North 21st Street, Suite 104, American Office Center
CITY STATE VP CODE
Camp Hill PA 17011 —
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY
(CHECK ONE)
7MO.• DAY YEAR
BTH TUESDAY 1
PRE-PRIMARY' FOR OFFICE USE ONLY
-- MD. DAY YEAA MO. DAY YEAR
2ND FRIDAY, - 2' DATER
REPORTING TO CJ N
PRE-PRIMARY PERIOD 01 01 201 123 1 JO 1 CC_
_W GFS
30 DAY
POSTPRIMARY r-1.3 A
- - CASH BALANCE AT END 500 . 00
a. OF REPORTING PERIOD: $ N
OTH;TUESDAY N
PRE-ELECTION
TOTAL AMOUNT OF FILER'S a A
` 5. OUTSTANDING DEBTS OR LIABILITIES
.2ND FRIDAY AT THE END OF REPORTING PERIOD: $ 0 . 00
PRE-ELECTION" --
..30 DAV .AMENDMENT
POST-ELECTIONYES NO XREPORT?
7.
ANNUAL TERMINATION
REPORT . - - Y' '.REPORT?- YES NO X
AFFIDAVIT SECTION
PARTI.
If statement is filed on behalf of a Political Committee orCandidates's Committee, the Treasurer must sign here.
If statement is filed on behalf of a Candidate,the Candidate must sign here.
If statement is filed on behalf of a Contributing Lobbyist, the Lobbyist must sign here.
I SWEAR(OR AFFIRM)THAT THE AGGREGATE RECEIPTS OR DISBURSEMENTS OR LIABILITIES INCURRED DURING THE
R�E9P�OLRITING PERIOD INDICATED ABOVE DID NOT
EXCEED TWO HUNDRED AND FIFTY DOLLARS($250.00)AND THIS REPORT IS,TO THE BEST OF MY KNOA�UEDN`—ter l ORRECT AND COMPLETE.
SWORN Tp AND SUBSCRIBED BEFORE ME THIS _
_D Y 2D SIGNATURE O SUBMITTING REPORT
F. Wilson Jackson, M. D.
PRINTED NAME
NATU E //'' /p
MY COMMISSION E RES 0 /`Tqa C?V/V 717 761-0930
CO ONWE YQ7-I OF'PENNSYLVANIA AREA CODE DAYTIME TELEPHONE NUMBER
PART II- KELLY R.HOWELL,Notary Public
If statement is filed on be If b€ dORf�t 0Z mittee, Candidate must sign here.
My Commiss+on xplr
i SWEAR(OR AFFIRM)THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THIS P UTICAL 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
MO. DAY YR.
Department of State * Bureau of Commissions,Elections and Legislation
DSEB-503(12-99) 2110 North Office Building * Harrisburg,PA 17120-0029 * (717)787-5280