Dffice of the Mi nesota Secretary of State
CAMPAIGN
INANCIAL REPORT CERTIF CATION QF F1L NG
lr struct ons
Eaci courtty, mun cipa or schoof district candidate or treasurer of a commit#ee formed to promote or defeat
ballot ques#ion shafl certify to the fling officer tha# a l reports required by Minnesota Statutes 21 A,02 have been
subtnitted to the fling officer or that the canclidate or committee has not recei ed contributions or made
disbursements ex eeding$ 75Q in the calendar year. The certitEcatlon shall be submitted ta the filing officer not later
han seven days after the general ar special e ectian. (Minnesota Statutes 211A.05, su6division }
Cam ai n Information
4 ,..
arste of candidate or co
r
mEttee..+
bv
r
O
ice
seu
ht by
Identifcatian
of
candidate(
t
R
Y
if ap p[ icabEe f. .
allot c{ uestion ( if applicabie)„
e,,
G
a„, . , „_„ „ ., ,
df
c c
1a
M„
p
R_
Certification
5elect the appropriate chaice below, and sign.
do swear( or affirm} that aEi campaign financial reports required by Minnesota Statutes 2 1A. 02 ha e bee
submit#ed# o the filing officer.
do swear( or afFirrrZ) tl at all cam{ aig cor tributio s or disbursements did not exceed$ 750 in the calendar
year.
s
Signa#ure
Date.
of candiciate or committee
9...
L.fo . ...
,. . .. .
,.
t
treasure ---
r
..
r'° ;
w ,
I
Revised 1/ 1014
CAMPAlGIV FlNAIVCIAL REPQRT
All of che infermetion in this report fs pu6lit information J
Name
ittee
candidate,
Office
so
ght or
bail
q
a'
ar corporatian
1 f CI
estion '
Candidate
1'
f
`
t
bj/
i [
O L(/
C+
District_
W A h0
Period of time ca ered by report:
repart
Campaign comrnittee report
report
Association
or corporation repart
from
Final report
S
to 1
CONTR BUTIONS RECEEVED
Give the total for ai cantributions recei ed during the periocf of time coveret! 6y this report. ContrihutioRs should e listed by type
mortey or in- kindj rather than contri6 tor. See note an contribution IirrEits on the back of this form. Use a separate sheet to itemize alE
contributions from a single source tf at exceeded$ IDO during the calendar year. This EtemFxation must include name, address, employer
or accupation i{ se[ f-emp oyed, amount and date for these cantri6utions.
0
a
CASH
TOTA! CASW- ON- HAND
j
$
iN- KEND
TQTAL AMOUNT REC NED
Oav Oa
DISBURSEMENTS
nclude t e amount, date and purpose for afl disbursements made during the period o time co ered by report.
Attach addit'sonal sheets if ecessary.
P1ate
P
Amaunt
arpose
r
u
O
I
TTL
CORpOiZATE PltOJECT EXPENDITURES
Corparations must list any media project or corporate message project for which contribution( s) or expenditure{ s) tatal
more than$ 200. Submit a separate report for each project. Attach additional sheets if necessary.
Pro; ect tit e or deseriptEon
D te
Furpos
N me Q rd fid ress
Expenditure ar
of Reciprent
C'antrfbutl n
Am unt
a
e
TTLI
z
ti
0
e
I certify that
his is
a
fulf
end tr
e statem
f
nt.
Signature
o+
Printed Narr
O
ti
Address
"
e
C
TelephoneL
i
o
S
5ate
Ta'".
fV ,
mail( if a aiEai Ee}
t
t
"
t, •
','
A!! of ihe Inj omretlon fn thls report fs puhftc
a . • .:
i'
a
i
Type a
ti.
i
r »
,
s
r-
V
CaRdEcfate re sort
Period of tirr e co ered by report:
Campai n comm tEee re ort
report
Pssociatian or corporatian report
from
F nal repart
l
to
CONTRiBEJTlONS RECEIVED
Give the tatal for all tontrib tions received during the periad of time covered by this re ort. Contri6utions should be 7isted by type
money or in- kind] rather than tontrikiutor. See note on cantribution limits on the backof this forrr. Use a separate sheet to itemiie ail
contrihutions from a sing e source that exceaded $ 10 dur(ng the calendar year. This itemization must :ncl de narne, address, employer
a
0
or occupattonif seEf- emplvyed, amount and date forthese cor tributions.
M .
G45H
TOTAL CASH- ON- HAND .
iV- KI fYD
TQTAL RMOUNT RECEIVED
r ;
DISBURS€ MENTS
Include the amount, date and purpose far all disbursements made furing the period of time covered by reporfi,
Attach acEditional sheets 9f necessary.
V
d
w
O
i •'
Corporations must [ ist any media project ar corporate message praject for wE ich contributfon(s} qr expenditure(s) total
more than $ 200. Submit a separate report for eac[ project. Attach additional s eets i# necessary.
f3 rt "
f'
p
e
Fatearr
i
r rtd A cfre ss
of Recipient '
E'x
r r i8c r
n
ib tio r
ourrt
T
Prir te
ddr ss
arn
t
r
Of ce of the Minnesota Secretary of State
i
1 ..
t: • #
Enstructio s
Each cosanty, mu ici a! ar school distritt candidat ar treasurer of a cammittee farmed ta promote or defeat a
balEot- question sha I certify to the fiiing of icer that aff reports required by Minnesata Statuies 211A. 2 have been
su6mitted to the fi[ing ofFicer or that the candidate or committee has not received contribution5 or made
dis6 rserr ents exceecifng $ 750 in the calendar year. The certifEtation shali e su6mi#ted ta the filing offPcer not Eater
than se en clays after the general or specia! election. {Minnesota Statutes 23.. A.05, su6divisian 1)
Cam ai n information
a . . . : ..
Name of canc date or committee C('•..:_ '' .
S.
w .,_„-
rt' _ ,
Office sought hy candidate (if applicablej=_v1laC
n,.
:
w
r
.
_.
g , .
Y6
.
:.
.
.
,
rv.
y ,.. ,. ._ . . .-.,. . ....
o- ... .
CC,.
C
R'
t
i d"
p
hd
. ..
v .
identificatian of ballot ques#ion ( if appficablej .
Certifieation
Sefect the app opriate choice be[ow, and sign.
I do swear( or affirmj that a1! campaign financial reports required by Minnesata 5tatutes 21 A.02 have been
s bmitted to the fiEing officer.
I do swear'(or affirm} that aii campaign coniributions or disbursements did nat exceed $ 750 in the calendar
year.
F.,,. ,. ..: ,,, . ,. . . :
Si nature af eandidate or committee treasurer;
Date;-;
IEC` T...
.. . . .. .
Revised 2/2014
RT
CAMPAIGN FINANCIAL REP
C
f`
4f1 of the fnficrmatFon in thfs reportls publFc ieformatlonJ
„
nramP
nf ca-
a'-'^*°
ittee
stson„
v
Y`
or corporation
r
r' j U[,`
t
District
-\
e '''
Type of
report
Period of time covered by report:
Candidate
seport
Campaign
committee report
Association
p/°
or carporation report
tb
to
fram -
Finai report
CON RtBUTIONS RECEfVEQ
Give the total for aji contri6utions received during the period of time [ overed by this report. Contributions should be I sted by type
money ar in-kind} rather than contributor. See note on contr9bufion limits on the back of this form. Use a separate sheet to itemize all
eontributions frorn a singie source that exceeded$ i0a duri g the calendar year. This itemizatian must include name, address, employer
p
or occupation if self-empEoyed, amount and date for these con#ributions.
ac
CASH
e
TOTAL CASH- ON- HAND
d
$
IN- KfND
TOTAf. AMOEIN
RECEIVED
=
Dl5BURSEMENTS
include the amount, date and purpose for all disbursements made during the period of time co ered by report.
Attach additional sheets if necessary.
ur
rae u at
s
e `
u
O
L
CORPORATE PltO fECT EXPENDIYURES
Corporatians must list any media project ar corporate message roject for which contribution{s) or expenditure( s) totaE
more ihan$
200. 5ubmit a
separate report
for
each projec#.
Attach additional sheets if necessary.
Praject tit€
e or descriptson
IVame
Purpose
Dafe
and
Fxpenditure or
Address
CantrfbutJon
of Recipient
Amount
T
TAL
z
s
g
..
o
I certify tha this€s a full and true statement.
w
Printed
Q
0
ti
5
3ame
C.
C
C1
1
Tefe p, one
,
nature
7
L,'
ate
Emasl ( if ava lable}
I
Y`
C.
p'
G `,
C
Address
-
1
b`(1'C-"
1(
J
M-
a
C, ,.
a
SG
1.
e
G
1CC
G
t
'
S
N
C
c
C
c
r-.
C
M`c
i
G
C'
r c
1
a
c
av
s
v
15`r- c, r•
w
6,'
C CG
Z —Z
.
6
M
Z
-
n
1
Z"
t4 , `°`
5 36
al2
l
y
CAI111PA GIV FINANCIAL REPORT
RFI ct the infarmatfon tn thls report fs pulrfic informationj
Nam
c
1`
r
Type
a
lot
mmittee or corporation
questiar.
('
r.
.
14RR
.
W r
Distric± w"' .—
COVT1,---
`'
Canaidate
of
I•
Period of time co ered by report:
report
Campaign comtn ttee report
report
Association
ar corporation report
from $
FinaE report
i
a
to
Z$
a
CONTRIBUFiQNS REGEIVED
Give the total for all contrEbutions received during the perfod af tirne covered by this report. CantributEons should be qsted by type
rrioney ar in- kind} rather than contributar. See noie on cantri6ution limits on the back o# this form. Use a separate sheet to item9ze all
contributions
0
from
a single source
that
exceeded$
00 durirtg the calendar year. This itemization must include name, address, emplayer
or oc[ upation ifself-employed, arnount a d date forthese contrlbutior s.
a
CASH
TOTAL CASH-
IV- HAND
$
If- K[ N
TOTAL AMOlJNT RECEIVED
=
D[ SBURSEMENTS
Include the amount, date and purpose for a! I disbursemersts made during the period of time co ered by report.
Attach addit9onal sheets if necessary.
bate
Purpase
Amaunt
u
m
O
T T L
CORPORATE PROJECT
XPENDITURES
Carporatians must list any media praject or corporate message project for which contribution( s} or expenditure(s} total
more than$ 200, 5 bmit a separate repart for each project. Attach additional sheets if necessary.
projecf titEe or description
Date
Purpose
fV
me
nd.
ddress
Fxpenditure
af Recipient
or
r
Cantrrbution
Amouat
a
TOTAL
oI certify that this
s a fuEi and true statement.
5ignature
y
Printed hdarne
O
f
Telephone
Date
rnail(;
f avaiiabEe)
F
t
L
Address__
l
L
l.
l
r
• "
a;
Al! of the information in thls report is publlc fnformatlonJ
arne of cand9date, c mrrai
Oific
i.
e or c rp ratEQn
sau ht or ball t questEa
t
istrict
Type of
Cat dida±e report
reQort
Campaign corrtmittee repart
t
C u;
Period of time covered by repart:
Association or corporation report
Firza! repart
CONTRiBIlTIONS RECEIVED
Give the tota!# ar all contributions reteived during the period of time covered hy this report. Contributians shoufd he listed by type
money or in- kind} rather thaR contributor. See note on contribut3on limits on the back of this form. Use a separate sheet to itemize al!
contributions from a single source tF a# exceeded $ IOQ during the calendar year. This itemization must include name, address, err3ployer
or occupation if self-empEoyed, amount and date for these centributians.
CASH $
t> '
OTALCASH- ON- HAND __
iN- KlND ¢
70TAL AMOU[ T REC NED
ISBURSEMENTS
inciudethe amount, date a d purpose for afl disbursements made during the perioc! of time coveretl 6y report.
Attachadditional sheets ifnecessary.
v
m
O
CORPQRATE PROJECT EXPENDITURES
Corporations must lisf any media project or corparate message project for whEch contribution(sj or expencEiture( s} to#al
more than $200. Submit a separate report for each pro ect. Attach additional sheets if hecessary.
Pr;
titl
r d s riptE r
at
t rp s°
r
f
C
j
r d, 4
E° p r ft r
r
of Recrprent
I
C' r trf6 r s rt
rra
unt
a
E
le
m
oT
z
a
L
a
L
0
a
S gRature
j
Prs t d 9Vast _ '
O
L
Addr ss 1
el
t'
g
E__ !
1
t
f
r i ii if a
il
E} .
q_ ,
Office of the Minnesota Seeretary of State
i
l
'
y ',.
r
.:..
1 ` .. ' .
r
nstru tions
Each county, rnur icipal or school district candidate ar# reasurer o#a cortzmittee formed to prarr ate or defeat a
6al ot question sha l certify to the filing officer #hat all re{ orts required by Minnesota Statutes 211A.02 have been
s bmitted to the filing afficer ar that the car didate or committee has not received can#ributior s ormade
disbursements exceeding $750 in the ca[er dar year. The certification shafl be submitted to the fiiing officer not later
than se en days afterthe general or specFal election. ( Minnesota Statutes 211A.05, subd'Nisian }
Cam ai n lnformation
n ,
Name of candidate or committee`; .,-...
Lw,,,
YC„!?.,
t r .
F
Office sought by candidate ( if app icable}: ,
r? ,
e
x .,. ..
u
... ,. _ . .- . .
Identification of baliat question ( if appEicable)
c,,
i-!
Ka.;, r¢
x;
:
.
.
.,
:
.
_,,.._.
LJ !
.
a„
t tC t!
Sefect tf e apprapriate cf oice below, and sign.
I do sw ar (or affirm) tf at al! campaign financia{ reports required hy Minr esota 5tatutes 2i1A.02 have been
submitted to the
ling officer.
f r o swear (or affirrr) that all campaign contributions ar disb rsements did no# exceed $ 750 in the calendar
year.
5ignature af can idate or comrrzittee treasur r./°`
Date .
1
t
C,..-._ ,-;
a.
Revised 2/ 2014