Daniel Palmerlee - 1989/09/24 - 1989/10/21
"
FORM 490
1989
CANDIDATE AND OFFICEHOLDER CAMPAIGN STATEMENT -. LONG FORM
AND
CONSOLIDATED CAMPAIGN STATEMENT
(Government Code Sections 84200-84217)
(Type or Print in Ink)
Statement covers period 9#2.-1. &'7 through It)- 2./,;,8,
CHECK ONE OF THE FOLLOWING BOXES TO INDICATE THE TYPE OF STATEMENT BEING FILED
II PRE-ELECTION STATEMENT 0 SUPPLEMENTAL PRE-ELECTION
o SEMI-ANNUAL STATEMENT STATEMENT (It filing a Supplemental
Pre-Election Statement, you must
complete Form 495 and attach It to
this statement,)
o TERMINA nON STATEMENT
Attach a Form 415 to this Form 490
CANDIDATE/OFFICEHOLDER INCLUDED IN THIS CONSOLIDATED REPORT
NAME OF CANDIDA TE/OFFICEHOLDER:
OFFICE SOUGHT OR HELD: (In(\ud.'o,"t10n .no 0''''''' number ,t ."",,,.01.)
RESIDENTIAL OR BUSINESS ADDRESS:
NO, AND STRfET
II CONTROLLED COMMITTEE* INCLUDED IN THI
NAME OF COMMITTEE:
I. 0 NUMBER
CITY
ST A TE
liP CODE
AREA COm/BUSINESS PHONE NUMBER
:R /J.. ~ ~Jifi
NAME OF TRE SURER:
~~
(,d
9~2/ -NJ8"84Z"2~9fI
NO, AND STRfEI
CITY
STATE
liP CODE
AREA CODE/BUSINESS PHONE NUMBE R
.. A controlled committee is one ' h is controlled directly or Indire a candidate or which acts jointly with a candidate or controlled committee in
connection with the making of expenditures. A candidate controls a commIttee" the candidate, the candidate's agent, or any other committee he or
she controls, has significant Influence on the actions or decisions of the committee.
III OTHER COMMITTEES: LIST ANY OTHER COMMITTEES NOT INCLUDED IN THIS CONSOLIDATED STATEMENT WHICH
ARE CONTROLLED BY YOU AND ANY COMMITTEES PRIMARILY FORMED TO RECEIVE CONTRIBUTIONS OR MAKE
EXPENDITURES ON BEHALF OF YOUR CANDIDACY
CONTROLLED
COMMITTEE NAME AND ID NUMBER COMMITTEE ADDRESS TREASURER COMMITTEE?
YES I NO
1/_...
Attach additional informatiOll OIl appropriately labeled continuatiOll sheets.
CANDIDATE OR OfFICEHOLDER:
I HAVE USED ALL REASONABLE DILIGENCE AND TO THE BEST OF MY KNOWLEDGE THE TREASURER HAS USED ALL REASONABLE DILIGENCE IN
PREPARING THIS STATEMENT. I HAVE REVIEWED THE STATEMENT AND TO THE BEST OF MY KNOWLEDGE THE INFORMATION CONTAINED
HEREIN ANDIN THE ATTACHED SCHEDULES IS TRUE AND COMPLETE. I CERTIFY UNDERPENA~TY 'PERJUR DER niE LAWS OF THE STATE OF
CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT. , / '1 ' /
""CUTED DN A,loot::."..~ dlilQAT # lr~, t'ld " ~;&:e>L-
~' (CITY DSTATEI (SlGHAnJAf fc.AHlllDATEOaOFfl(EHOl.DfRl
TREASURER (if applia~l:
I HAVE USED AU REASONABLE DILIGENCE IN PREPARING THIS STATEMENT AND TO THE BEST OF MY KNOWLEDGE THE INFORMA TION
CONTAINED HEREIN AND IN THE ATTACHED SCHEDULES IS TRUE AND COMPlETE.
ICERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
EXOCUTEDD~l'J4Nt?AT h. C,4 BY (]VJ&jlJJ AxJ1.~d
!DArtl t ~..cfSTAnl' (SI4HAlUlt Of I .JlE~1
\
VERI FICA TlON
PAGE :L OF /7
ALLOCATION PAGE
FORM 490
STATEMENT COVERS PERIOD
FROM THROUGH
I/LJ, D..B~
M
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
LIST CONTRIBUTIONS AND INDEPENDENT EXPENDITURES TOTALING $100 0 0 ADE FROM THE CANDIDA TE'S OR OFFICEHOLDER'S PERSONAL
FUNDS TO SUPPORT OR OPPOSE OTHER OFFICEHOLDERS. CANDIDATES AND COMMITTEES. (SEE INSTRUCTIONS ON REVERSE.)
INDif NAME OF CANDIDATE. OFFICEHOLDER OR COMMITTEE CHECK ONE CUMULA TIVE
DATE AMOUNT TO DA TE
EXP.
SUPPORT OPPOSE
CALENDAR YEAR
$
J/_ FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
CALENDAR YEAR
- $
FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
*See reverse regarding independent expenditures. SUBTOTAL $ -0-
SUMMARY
1. CONTRIBUTIONS OF $100 OR MORE MADE THIS PERIOD OUT OF PERSONAL FUNDS
(Include all Allocation Page Subtotals) ............."."....................."...."""..........". "............
$ -I)-
2. CONTRIBUTIONS UNDER $100 MADE THIS PERIOD OUT OF PERSONAL FUNDS (Not
itemized) ..... ......... ",.. "... ..... ......."......".. ...",. .. ".".. ,...............,,".. ....... "..... "... ..... "..... ....
-~-
3. TOTAL CONTRIBUTIONS MADE THIS PERIOD OUT OF PERSONAL FUNDS (Do Not carry
thistotaltotheSummaryPage). ... ....."..... ....".............""..".................,,...
$...LJ ..
PAGE 5
OF /7
CAMPAIGN DISCLOSURE STATEMENT SUMMARY PAGE
FORM 490
(Amounts May Be Rounded To Whole Dollars)
lAM I.D. NUMBER
:ONTRIBUTIONS RECEIVED COLUMN A COLUMN B COLUMN C
Cumulative total Total thisJerJod from Cum ulative to date
from previous period* attache schedules (Columns A + B)
1. Monetary contributions. .................... $ 992. ~ ~() $ '/..-f4.f/.tJlJ $ ~/.IJIJ
SCHEDULE A, LINE J
2. Loans received. ............................ .0. - {J- -()-
SCHEDULE B, LINE 7
3. SUBTOTAL CASH RECEIPTS. . . .. ... . . ... . ... . $ 992. # "tL $ 2.4tJ1l ~ $ 3Jt!JI.IJO
LINES 1 + 2 LINES 1 + 2 LINES 1 + 2
4. Non-monetary contributi'Ons. . . . . . . . . .'. . . . . . -l?... 5J.~q, 5'.~
SCHEDULE C. LINE J
5. TOTAL CONTRIBUTIONS WITHOUT
ENFORCEABLE PROMISES. . . . . . . . . . . . . . . . . . . CJ 9t. # IJO ~()~~ f3452.~~
Enforceable Promises (Except loan LINES J . 4 LINE S 3 + 4 L1NESJ .4
6. -()- -CJ- -0-
guarantees, see Line 18 below)... ...........
SCHEDULE D. LINE 7
7. TOTAL CONTRIBUTIONS. . . . . . . . . . . . . . . . . . . . $ 9"JL. ~lJ $ '2~.~ $ ..-3452,,~
LINES 5 + 6 LINE S 5 + 6 LINES 5 . 6
:XPENDITURES MADE (SHOULD EQUAL LINE 7,
$ la~, "" $ COLUMNS A ~"
$ -0- JCJ5a
8. Payments. . . . . . . . . . . . . . . . . .'. . . . . . . . . . . . . . . SCHEDULE E, LINE 5
9. Loans Made. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -0- -{J- -(J-
SCHEDULE EE, LINE 7
10. SUBTOTAL............................... . -/)- I~+'~ /()3(JM/,6:J
. LINES 8 + 9 L1NES8.9 LINES 8 . 9
11. Accrued expenses (u-npaid bills) . . . . . . . . . . . . . L./.. 5lJ (4.9/~ I'.S!}
SCHEDULE F, LINE 5
12. TOTAL EXPENDITURES. '" .. . . .. . . .. ... . ... $ ~~/.l5IJ $ ItJK~5 $ 1tJ47.2S
LINES 10 . 11 LINES 10 + 11 LINES 10 . 11
(SHOULD EQUAL LINE 12.
COLUMNS A . B)
*IF THIS IS THE FIRST REPORT FILED FOR THE CALENDAR YEAR, COLUMN A SHOULD BE BLANK
EXCEPT FOR LINES 2, 6, 9 AND 11.
STATEMENT OF CHANGES IN FINANCIAL CONDITION
13. Cash on hand at the beginning of this period. (Enter "Cash on hand
at end of reporting period" from previous statement filed.) . . . . . . . .
14. Cash receipts this period (Line 3, Column B above) . . . . . . . . . . . . . . . . . . .
15. Miscellaneous increases to cash (Schedule G, Line 4) ....... . . . . . . . . . .
16. Cash payments this period (Line 10, Column B above) . . . . . . . . . . . . . . . .
17. Cash on hand at end of reporting period (Lines 13 + 14 + 15 - 16 above)
(Ifthis is a Termination Statement, Line 17 must be Zero.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18. Amount of loan guarantees received (Schedule B, Part I, Column (b)). .. .. . .. . ....... . ..... .
19. Cash equivalents (other assets held including outstanding loans made to others).
Important: See instructions on reverse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20. Outstanding debts (Line 2 + Line 11 of Column C above). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
~"2..IJ{)
?-4/J9, no
-0-
Itl'5I'J. f#~
$ fl.~'1'l).. ~
ENDING CASH ON HAND SHOULD
NOT BE A NEGATIVE AMOUNT
$ -0-
$ --0-
$ J~.e;
SUMMARY FOR CANDIDATES IN BOTH A JUNE AND NOVEMBER ELECTION (See Instructions on Reverse)
1/1 THRU 6130
7/1 TO DATE
21. CONTRIBUTIONS RECEIVED:
22. EXPENDITURES MADE:
.3~.52.,~
/fH7. 2.5
SCHEDULE A
MONETARY CONTRIBUTIONS RECEIVED
FORM 490
(Amounts May Be Rounded To Whole Dollars)
'''-/4-1'1
ID-I'-sct
/0-/8./9
SUMMARY
PAGE 4. OF /7
STATEMENT COVERS PERIOD
FROM THROUGH
J
I.D, NUMBER
EMPLOYER
AMOUNT
(If SElf.EMPLOYEO, ENTER
NAME OF BUSINESS)
OCCUp tlOn: , ,
RECEIVED
THIS PERIOD
CUMULA TlVE
TO DA TE
CALENDAR YEAR:
$
FISCAL YEAR:
$
Employer:
Occup~tion:
CALENDAR YEAR:
$
FISCAL YEAR:
$
Occupation:
. .
CALENDAR YEAR:
$
EmPIOyertl:~ .>p,rtfTt/
~ .Y~ Sf4f~
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
~-W~ir;
FISCAL YEAR:
$
Occupation:
CALENDAR YEAR:
$
Employer:
FISCAL YEAR:
$
CALENDAR YEAR:
$
Occupation:
Employer:
FISCAL YEAR:
$
SUBTOTAL
$ 15C. (JO
1. AMOUNT RECEIVED THIS PERIOD -- CONTRIBUTIONS OF $100 OR MORE
(Include all Schedule A subtotals) . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . .
2. AMOUNT RECEIVED THIS PERIOD -- CONTRIBUTIONS OF LESS THAN $100 (Not
itemized). . . . . . . . . . .. . . . . . . . . . . . . . . . , . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. TOTAL MONETARY CONTRIBUTIONS RECEIVED THIS PERIOD
(Line 1 + Line 2) Enter here and on Line 1, Column B of Summary Page. . . . . . . , . . . . . .
$ '15tJ~()O
/"S~IJ()
$ R.4()~ tJO
SCHEDULE A
MONETARY CONTRIBUTIONS RECEIVED
(CONTINUATION SHEET)
FORM 490
(Amounts May Be Rounded To Whole Dollars)
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
DATE
REC'D.
FULL NAME AND ADDRESS OF CONTRIBUTOR
OCCUPATION
EMPLOYER
(IF COMMITTEE, IN ADDITION TO COMMITTEE'S NAME AND ADDRESS,
ENTER 1.0, NUMBER OR, IF NO I,D, NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
(IF SELF.EMPLOYED, ENTER
NAME OF BUSINESS
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
OccupatIOn:
Employer:
Occupation:
Employer:
SUBTOTAL
\GE 5' OF /7
STATEMENT COVERS PERIOD
FROM I THROUGH
fj.J:A.B'7 ,/0-2.1-6'7
D, NUMBER
AMOUNT
RECEIVED CUMULATIVE
THIS PERIOD TO DA TE
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
$
SCHEDULE B -- LOANS RECEIVED (PART 1)
FORM 490
(Amounts May Be Rounded To Whole Dollars)
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
))l1JUL lJ. ~Y/elliJJ.., 7airrJnu~ I'~~ t'mn~
PART I: LOANS RECEIVED
DATE
REC'D,
FULL NAME AND ADDRESS OF LENDER
OCCUPATION
EMPLOYER
INT
RATE
(IF COMMITTEE, IN ADDITION TO COMMITTEE'S NAME ANO ADDRESS,
ENTER 1.0. NUMBER OR, IF NO I.D NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
(If SELf-EMPLOYED, ENTER
NAME OF BUSINESS)
Occupation:
Employer:
Occupation:
Employer:
PAGE
b OF 17
STATEMENT COVERS PERIOD
FROM THROUGH
/I.D_ NUMBER
&6~~'11
DUE
DATE
AMOUNT CUMU-
OF LOAN LATIVE
TO DATE
CALENDAR YEAR
$
FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
SUBTOTAL
FULL NAME AND ADDRESS OF GUARANTOR
OCCUPA nON
EMPLOYER
(IF SElF.EMPLOYED, ENTER
NAME OF BUSINESS)
Occupation:
(IF COMMITTEE. IN ADDITION TO COMMITTEE'S NAME AND ADDRESS,
ENTER 1.0, NUMBER OR, IF NO I.D NUMBER HAS BEfN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
: NAME Of LENDER
Employer:
: NAME Of lENDER
Occupation:
Employer:
SUBTOTAL
DO NOT CARRY THIS AMOUNT TO THE
SUMMARY BELOW, ENTER ON LINE 18
OF THE SUMMARY PAGE.
SUMMARY
1. LOANS OF $100 OR MORE RECEIVED THIS PERIOD (Part 1 (a)) . . . . . . . . . . . . . . . . . . . . . .
2. LOANS UNDER $100 RECEIVED THIS PERIOD (Not itemized)........................
3. TOTAL LOANS RECEIVED THIS PERIOD (Line 1 + 2). . . . . . . . . . . . . . . . .. . ... . . .. . . . . ..
4. LOANS OF $100 OR MORE REPAID, FORGIVEN OR PAID BY A THIRD PARTY
THIS PERIOD (Part 2, Column (c)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. LOANS UNDER $100 REPAID, FORGIVEN OR PAID BY A THIRD PARTY
(not previously itemized) (If forgiven or paid by a third party, also enter
amount on Line 2 of the summary section of Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . .
6. TOTAL LOANS REPAID, FORGIVEN OR PAID BY A THIRD PARTY THIS PERIOD
(Line 4 + 5). . . . . . . . . . . _ . . . . . . , . . . . , . _ . . . . . . , , . . . . . . . _ . , . . . . , . . . . . . , . . . . . . . . . . .
7. NET CHANGE THIS PERIOD (Subtract Line 6 from Line 3)
Enter the difference here and on Line 2, Column B of Summary Page. . . . . . . . . . . . . . .
~:t~~illil"'$'ifl~
,f."':'~'$;;~~~~m:~~'t,:,:.
"~W%&i8W~~$.F~~
"';;:'lfkt:l}'%;:::::~J":~';::::'
ill0it(~1~~1111~
AMOUNT
GUARANTEED
CUMU-
LA TIVE
TO DATE
CALENDAR YEAR
$
THIS
PERIOD
FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
(May be neg.
atlv~ figurel
SCHEDULE B -- LOANS RECEIVED (PART 1)
(CONTINUATION PAGE)
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PAGE
7 OF 17
STATEMENT COVERS PERIOD
FROM THROUGH
PART I: LOANS RECEIVED
DATE
RECD
FULL NAME AND ADDRESS OF LENDER
OCCUPA TION
EMPLOYER
INT DUE AMOUNT
RATE DA TE OF LOAN
CUMU-
LA TIVE
TO DATE
(IF COMMITTEE, IN ADDITION TO COMMITTEE'; NAME AND ADORE;;,
ENTER 1.0, NUMBER OR, IF NO J.D, NUMBER HAb BEEN ASSIGNED,
ENTER THE TREASURER'; NAME AND ADDRESS)
(If SU f-EMP' DYED, ENTER
NAME Of BUSINE SS)
OCCU~iIlIUIl ,
CALENDAR YEAR:
S
Employer:
fiSCAL YEAR:
S
Occupation:
CALENDAR YEAR:
Employer:
fiSCAL YEAR
S
OCCupation:
CALENDAR YEAR:
Employer:
fiSCAL YEAR:
S
SUBTOTAL
AMOUNT
GUARANTEED
THIS CUMU-
PERIOD LATIVE
TO DATE
FUll NAME AND ADDRESS OF GUARANTOR
NAME Of LENDER
OCCUPA TION
EMPLOYER
(If SELF-EMPLOYED, ENTER
NAME Of BUSINESS)
Occupation:
CALENDAR YEAR:
(IF COMMITTEE, IN ADDITION TO COMMITTEE'S NAME AND ADDRESS,
ENTER I.D, NUMBER DR, If NO ID NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
Employer:
fiSCAL YEAR:
S
NAME Of LENDER
Occupation:
CALENDAR YEAR:
S
Employer:
fiSCAL YEAR:
S
NAME Of LENDER
Occupation:
CALENDAR YEAR:
Employer:
FISCAL YEAR:
S
NAME Of LENDER
Occupation:
CALENDAR YEAR:
S
Employer:
FISCAL YEAR:
S
(b)
SUBTOTAL
-o~
SCHEDULE B -- LOANS RECEIVED (PART 3)
ANNUAL REPORT OF OUTSTANDING LOANS RECEIVED
FORM 490
PAGE ,;
OF/7
(Amounts May Be Rounded To Whole Dollars)
LD, NUMBER
PART 3 -- ANNUAL REPORT OF OUTSTANDING LOANS RECEIVED -- SEE INSTRUCTIONS ON REVERSE BEFORE COMPLETING.
FULL NAME OF THE LENDER
ORIGINAL DATE
OF LOAN
AMOUNT OF
ORIGINAL LOAN
UNPAID
PRINCIPAL
UNPAID
INTEREST
.0-
TOTAL $
(NO fE: THIS TOTAL
SHOULD BE THE SAME
AMOUNT AS ENTERED
ON LINE 2, COLUMN C
OF THE SUMMARY PAGE)
SCHEDULE B -- LOANS RECEIVED (PART 2)
FORM 490
PAGE
9
OF 11
(Amounts May Be Rounded To Whole Dollars)
;69
PART 2: LOAN REPAYMENTS MADE, LOANS FORGIVEN OR PAl
DATE OF
REPAY-
MENTOR
FORGIVE-
NESS
DATE OF
ORIGINAL
LOAN
FULL NAME OF LENDER
INT,
RA TE (IF FORGIVEN*
CHANGED)
AMOUNT REPAID
OR FORGIVEN ON
PRINCIPAL (DO NOT
INCLUDE PAYMENT
OF INTEREST)
OUTSTANDING
PRINCIPAL
INTEREST
PAID**
* IMPORTANT: IF ANY PART OF A LOAN IS FORGIVEN OR REPAID BY A THIRD PARTY, THE PERSON
FORGIVING THE LOAN OR THE THIRD PARTY MAKING THE PAYMENT AND THE AMOUNT
FORGIVEN OR PAID MUST BE ITEMIZED ON SCHEDULE A, WITH A NOTATION SUBTOTAL
THAT IT IS A FORGIVEN LOAN, OR THIRD PARTY REPAYMENT OF LOAN
(C)
$ .0-
* *TOTAL All LNTfRE ST PAID THIS PERIOD AL SO ENTER
ON liNE J Of THE SUMMARY SECTION Of SCHEDULE E,
DO NOT CARRY THIS TOTAL TO THE SCHEDULE 8 SUMMARY
TOTAL INTEREST PAID
THIS PERIOD
(d)
$ -0 ..
SCHEDULE C
NON-MONETARY CONTRIBUTIONS RECEIVED
FORM 490
PAGE
10 OF /7
(Amounts May Be Rounded To Whole Dollars)
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
#
LD NUMBER
/~D/
19'1
FULL NAME AND ADDRESS
OF CONTRIBUTOR
(IF COMMITTEE, IN AOOITION TO COMMITTEE'S
NAME ANO AODRESS, ENTER 1.0 NUMBER
OR, IF NO 1.0. NUMBER HAS BEEN ASSIGNED. (IF SELF.EMPLOYED, ENTER
ENTER THE TREASURER'S NAME AND ADDRESS) NAME OF BUSINESS)
cthlfTnilS ~ Occupation:
4~'?{) ~.Jiss:~ Em
9/~, CJd. 954Zl>
EMPLOYER
DESCRIPTION OF
GOODS OR SERVICES
FAIR
MARKET
VALUE
RECEIVED
CUMU-
LA TIVE
AMOUNT
...
.t as:e)t'/TJt
loyer: ~W~
CALENDAR YEAR:
$
~,5;.
FISCAL YEAR:
$
Occupation:
CALENDAR YEAR:
$
Employer:
FISCAL YEAR:
$
Occupation:
CALENDAR YEAR:
$
Employer:
FISCAL YEAR:
$
Occupation:
CALENDAR YEAR:
$
Employer:
FISCAL YEAR:
$
Occupation:
CALENDAR YEAR:
$
Employer:
FISCAL YEAR:
$
CALENDAR YEAR:
$
Occupation:
Employer:
FISCAL YEAR:
$
Occupation:
CALENDAR YEAR:
$
Employer:
FISCAL YEAR:
$
SUBTOTAL
$ 51.:J(p
SUMMARY
1. NON-MONETARY CONTRIBUTIONS OF $100 OR MORE RECEIVED THIS PERIOD........ $ -()-
2. NON-MONETARY CONTRIBUTIONS UNDER $100 RECEIVED THIS PERIOD (Not
itemized). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . 51. 3(p
3. TOTAL NON-MONETARY CONTRIBUTIONS RECEIVED THIS PERIOD
(Line 1 + Line 2) Enter here and on Line 4 Column B of Summary Page. . . . . . . . . . . . . . . $ 51. 3t,
PAGE II OF /'7
STATEMENT COVERS PERIOD
FROM THROUGH
1.0. NUMBER
85""'1
AMOUNT CUMU-
PAID LA TIVE
THIS PERIOD AMOUNT
(ALSO ENTER ON UNPAID
SCHEDULE A)
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
CALENDAR YEAR:
$
FISCAL YEAR:
$
(b)
$ -0"
SCHEDULE D
ENFORCEABLE PROMISES RECEIVED
(Other Than Loan Guarantees,
Loan Endorsements and Loan Security)
FORM 490
NOTE: Loan guarantees, loan endorsements and loan security are
"enforceable promises." However, such promises must
be reported on Schedule 8, NOT Schedule D.
(Amounts May Be Rounded To Whole Dollars)
DATE
REC'D.
FULL NAME AND ADDRESS
OF CONTRIBUTOR
(IF COMMITTEE, IN ADDITION TO COMMITTEE'S
NAME AND ADDRESS, ENTER I.D NUMBER
OR, IF NO 1.0. NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
(IF SELf.EMPLOYED, ENTER
NAME OF BUSINESS)
Occupatlun:
EMPLOYER
AMOUNT
PROMISED
THIS PERIOD
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
OccupatIon:
Employer:
SUBTOTAL $
(a)
-~..
SUMMARY
$
1. PROMISES RECEIVED OF $100 OR MORE THIS PERIOD (Column (a)). . . . . . . . . . . . . . . . . . .
2. PROMISES RECEIVED UNDER $100 THIS PERIOD (Not itemized).... ... .. . ..... ... .. . .
3. TOTAL PROMISES RECEIVED THIS PERIOD (Line 1 + 2).......... .... . . _ . ... .. . . . . . .
4. PAYMENTS ON PROMISES OF$1000RMORE RECEIVED THIS
PERIOD (Column (b)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. PAYMENTS ON PROMISES UNDER $100 RECEIVED THIS
PERIOD (Not itemized) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Also enter on Line 2 of the summary section of Schedule A)
6. TOTAL PAYMENTS ON PROMISES RECEIVED (Line 4 + 5).... . . . . . . . . . . . . . . . . . . . . . . .
7. NET CHANGE THIS PERIOD (Subtract Line 6 from Line 3)
Enter the difference here and on Line 6. Column B of Summary Page. . . . . . . . . . . . . . . .
-0-
-0-
(May oe neg-
atlv~ figure)
SCHEDULE E
PAYMENTS AND CONTRIBUTIONS (OTHER THAN LOANS) MADE
FORM 490
PAGE 1:2. OF 1'7
STATEMENT COVERS PERIOD
(Amounts May Be Rounded To Whole Dollars)
If one of the following codes is used to describe the expenditure, no written description is needed. (Note exceptions
on the back of this schedule for code 'T'.) Refer to the back of this schedule and the back of the Schedule E
Continuation Sheet for detailed explanations of each category.
"L" -- LITERATURE
"B" -- BROADCAST ADVERTISING
"N" -- NEWSPAPER AND PERIODICAL ADVERTISING
"0" -- OUTSIDE ADVERTISING
"S" -- SURVEYS, SIGNATURE GATHERING, DOOR- TO-DOOR
SOLICITATIONS
"F" -- FUNDRAISING EVENTS
"G" -- GENERAL OPERATIONS AND OVERHEAD
"T" -- TRAVEL, ACCOMMODATIONS AND MEALS
"P" -- PROFESSIONAL MANAGEMENT AND
CONSULTING SERVICES
If one of the above codes does not accurately or fully describe the expenditure, leave the "Code" column blank and
provide a written description in the "Description of Payment" column.
IMPORTANT: Do not itemize the payment of accrued expenses on Schedule E. Report only the lump sum of these
payments on Line 4 of the Summary section, below.
NAME AND ADDRESS OF PAYEE, CREDITOR OR
RECIPIENT OF CONTRIBUTION
(If COMMITTEE. IN ADDIlION TO COMMITTEE'S
NAME ANO ADDRESS, ENTER 1.0, NUMBER
OR,lf NO I.D, NUMBER HAS BEEN ASSIGNED, ENTER THE
TREASURER'S NAME AND ADDRESS)
AMOUNT
PAID
CODE OR DESCRIPTION OF PAYMENT
~~~~
r;r~" C.,4 Q5()Z[)
74Ut A::Ice~r
8-1#1 IJetfa,
fin J C"14 9S"W
one :l1't.nfi71t/ ~
StJ/ /sr SJ:'
i/n C,c Q5/)UJ
?~S 1J~.Ja.r$ ~~W13
andi~ staremml"-
1J:anislll'7YNlslatt0t,
.:Preci~ .b1d'~~
8 nf'
,
., ,M',
I~
f52Z.1.
F
SUBTOTAL
6IJ. ()()
$ ~I .
SUMMARY
1. PAYMENTSOF$1000RMOREMADETHISPERIOD $
(Include all Schedule E subtotals) .....,.......,.,.......,.......,.,..,.......,...,......."...,....,.,....,.,........,.....,...
849.iJlL
/59.5i:J
2. PAYMENTS UNDER $100 THIS PERIOD (Not itemized) _..............................................................
3. TOTAL INTEREST PAID THIS PERIOD ON OUTSTANDING LOANS
(Schedule B, Part 2, Column (d)) ................... .........................
-LJ.
'2./. 50
4. TOTAL ACCRUED EXPENSES PAID THIS PERIOD (Not itemized) (Schedule F, Line 4)..................
5. ~~~~La~: ;~~N.~.~.~~I~ ,P.E.R.I~~.~~i.~.e,.1. ,+,~ ..+. .3,,~. ~~..E,~,t~r,~~r~a,n,~,~~.L.i.~.~.~:.~~I.~.~,~,.~.~f........ ~~(J. ,,~
SCHEDULE E
PAYMENTS AND CONTRIBUTIONS (OTHER THAN LOANS) MADE
(CONTINUATION SHEET)
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PAGE
/.3 OF 17
A 'V-4'1
",
I.D. NUM,BER
CODES FOR CLASSIFYING EXPENDITURES
If one of the following codes is used to describe the expenditure, no written description is needed. Refer to the back
of this schedule for detailed explanations of each category.
"L" -- LITE RA TURE
"B" -- BROADCAST ADVERTISING
"W - NEWSPAPER AND PERIODICAL ADVERTISING
"S" - SURVEYS, SIGNATURE GATHERING, DOOR-TO-DOOR
SOLICITATIONS
"0" - OUTSIDE ADVERTISING
"F" -- FUNDRAISING EVENTS
"G" -- GENERAL OPERATIONS AND OVERHEAD
"T" -- TRAVEL, ACCOMMODATIONS AND MEALS
"P" -- PROFESSIONAL MANAGEMENT AND
CONSULTING SERVICES
If one of the above codes does not accurately or fully describe the expenditure, leave the "Code" column blank and
provide a written description in the "Description of Payment" column.
NAME AND ADDRESS OF PAYEE, CREDITOR OR
RECIPIENT OF CONTRIBUTION
(If COMMITTEE, IN ADDITION TO COMMITTEE'S
NAME AND ADDRESS. ENTER I,D, NUMBER
OR, If NO 1.0, NUMBER HAS BEEN ASSIGNED, ENTER THE
TREASURER'S NAME AND ADDRESS)
AMOUNT
PAID
CODE OR
DESCRIPTION OF PAYMENT
L .25.~C
F
'l!rttSt'rJ'
,
SUBTOTAL
$
!lB'?,18
SCHEDULE EE
LOANS MADE TO OTHERS
FORM 490
(Amounts May Be Rounded To Whole Dollars)
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
*'
PART!: LOANS MADE TO OTHERS
DATE
OF
LOAN
FULL NAME AND ADDRESS OF RECIPIENT
INTEREST
RATE
DUE DATE
SUBTOTAL
PAGE /4 OF 1'/
1.0. NUMBER
AMOUNT
CUMULA TIVE
AMOUNT
$ "0-
PART 2: LOAN REPAYMENTS RECEIVED BY THIS CANDIDATE, OFFICEHOLDER OR COMMITTEE AND LOANS FORGIVEN
BY THIS CANDIDATE, OFFICEHOLDER OR COMMITTEE
DATE OF
REPAY- DATE OF
ME NT OR ORIGINAL
FORGIVE- LOAN
NESS
FULL NAME OF
RECIPIENT OF LOAN
FORGIVEN/PAID BY THIRD PARTY AMOUNT REPAID OUT-
INT, OR FORGIVEN ON STANDING INTEREST
RA TE (IF fORGIVEN lOANS: Enter "Forgiven.. Also PRINCIPAL (00 NOT PRINCIPAL RECEIVED*
CHANGED) itemize for Iven loans on Schedule E. INClUDE RECEIPT
PAYMENT BY THIRO PARTY: Enter name OF INTEREST)
SUBTOTAL $
*TOTAl AU INTEREST RECEIVED THIS PERIOD. ALSO ENTER
ON LINE) OF THE SUMMARY SEcnON OF SCHEDULE G. DO
NOT CARRY THIS TOTAL TO THE SUMMARY BElOW.
SUMMARY
1. LOANS OF $100 OR MORE MADE THIS PERIOD (Part 1) . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . $
2. LOANS UNDER $100 MADE THIS PERIOD (Not itemized). . . . . . . . . . . . . . . . . . . . . . . , . . . . .
3. TOTAL LOANS MADE (Line 1 + 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . .
4. PAYMENTS RECEIVED ON LOANS OF $100 OR MORE (Including a forgiveness
or payment by a third party) (Part 2, Column (a)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. PAYMENTS RECEIVED ON LOANS UNDER $100 (Including a forgiveness
or payment by a third party) (Not itemized) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. TOTAL LOAN REPAYMENTS RECEIVED THIS PERIOD (Line 4 + 5). . . .. " . . . . . .. . .. ...
7. NET CHANGE THIS PERIOD (Subtract Line 6 from Line 3)
Enter the difference here and on Line 9, Column B of Summary Page. . . . . . . . . . . . . . . .
(a)
"0-
SCHEDULE EE -LOANS MADE TO OTHERS (PART 3)
ANNUAL REPORT OF OUTSTANDING LOANS MADE
FORM 490
(Amounts May Be Rounded To Whole Dollars)
"AGE
1.'5" OF J'1
N ME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
"
,-D. NUMBER
PART 3: ANNUAL REPORT OF OUTSTANDING LOANS MADE
BEFORE COMPLETING.
FULL NAME OF RECIPIENT OF LOAN
ORIGINAL
DATE
OF LOAN
AMOUNT
OF
ORIGINAL
LOAN
UNPAID
PRINCIPAL
UNPAID
INTEREST
SUBTOTAL
$
"0-
(NOTE: THIS TOTAL
SHOULD BE THE SAME
AMOUNT AS ENTERED
ON LINE 9, COLUMN C
OF THE SUMMARY
PAGE,)
SCHEDULE F
ACCRUED EXPENSES
(UNPAID BILLS)
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PAGE /~ OF 1'1
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
I.D, NUMBER
..
CODES FOR CLASSIFYING ACCRUED EXPENSES
If one of the following codes is used to describe the accrued expense, no written description is needed. (Note
exceptions on the back of this schedule for code "T".) Refer to the back of this schedule for detailed explanations of
each category.
"L" -- LITERATURE
"B" -- BROADCAST ADVERTISING
"N" -- NEWSPAPER AND PERIODICAL ADVERTISING
"0" -- OUTSIDE ADVERTISING
"S. -- SURVEYS, SIGNATURE GATHERING, DOOR-TO-DOOR
SOLICITATIONS
'T' u FUNDRAISING EVENTS
"G" -- GENERAL OPERATIONS AND OVERHEAD
"T" -- TRAVEL, ACCOMMODATIONS AND MEALS
"P" -- PROFESSIONAL MANAGEMENT AND
CONSULTING SERVICES
If one of the above codes does not accurately or fully describe the expenditure, leave the "Code" column blank and
provide a written description in the "Description of Outstanding Payment" column.
NAME AND ADDRESS OF PA YEE, CREDITOR
OR RECIPIENT OF CONTRIBUTION
(IF COMMIITEE, IN ADDITION TO COMMITTEE'S
NAME AND ADDRESS, ENTER I.D, NUMBER AMOUNT
OR, IF NO I.D, NUMBER HAS BEEN ASSIGNED. ENTER THE CODE OR DESCRIPTION OF OUTSTANDING PAYMENT
TREASURER'S NAME AND ADDRESS' ACCRUED
.Irani:s yartlinllcl'isP
oS J~ ;;q
I
-"
SUBTOTAL
IMPORTANT: Do not itemize the payment of accrued expenses on Schedules E or F. Report the lump sum of these
payments on Schedule F, Line 4 and on Schedule E, Line 4. Do not re-itemize accrued expenses which have been
reported in a previous period.
SUMMARY
1. ACCRUED EXPENSES OF $100 OR MORE THiS ?ERIOD '.............
(May be
negative figure)
2. ACCRUED EXPENSES OF UNDER $100 THIS PERIOD (Not itemized)
3. TOTAL ACCRUED EXPENSES INCURRED THIS PERIOD (Line 1 + 2) ...........................
4. ACCRUED EXPENSES PAID THIS PERIOD (Not itemized) (Enter here
and on Schedule E, Line 4) ,.... ..... ..... .......,.. ..... ..... .............,.... .......... ........., ...........
S. NET CHANGE THIS PERIOD (Subtract Line 4 from Line 3) Enter difference here and on
Line 11, Column B of Summary Page ..................................................................