Daniel Palmerlee - 1989/10/22 - 1989/12/31
FORM 490
1989
CANDIDATE AND OFFICEHOLDER CAMPAIGN STATEMENT -- LONG FORM
AND
CONSOLlDA TED CAMPAIGN STATEMENT
(Government Code Sections 84200-84217)
(Type or Print in Ink)
Statement covers period A . through /2.-iJ/ "l??
CHECK ONE OF THE FOLLOWING BOXES TO INDICATE THE TYPE OF STATEMENT BEING FILED
~ PRE-ELECTION STATEMENT 0 SUPPLEMENTAL PRE.ELECTION
tf SEMI-ANNUAL STATEMENT STATEMENT (If filing a Supplemental
Pre-Election Statement. you must
complete Form 495 and attach It to
this statement,)
o TERMINATION 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<lude Io<ouon and d'>tr"t numoer It dWli,."le)
RESIDENTIAL OR BUSINESS ADDRESS:
NO, AND STRfET
AKeA COOe/ijUSINlSS PHONe NUMijeR
II CONTROLLED COMMITTEE'" INCLUDED IN THIS
NAME OF COMMITTEE:
I. 0 NUMBEK
ADDRESS OF COMMITTEE:
N~E ~'TREAl~f 65B
STATE
liP CODE
AREA COOL/BUSINESS PHONe NUMBeR
(jilY-tJ
C>4
95(J2J 4()B. !J47-1A.J:A
CITY
STAlE
liP CODE
AREA CODe/BUSINESS PHONE NUMBe R
· A controlled committee is one whic . on trolled directly or indirectly ya 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 signifitant 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 I.D, NUMBER COMMITTEE ADDRESS TREASURER COMMITTEE'
ns NO
AL_~ ...
Attach additional information on appropriately labeled continuation 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 NOWLEDGE INfORMATION CONTAINED
HEREIN ANDIN THE ATTACHED SCHEDULES IS TRUE AND COMPLETE. I CERTIFY UNDER PENAL Of! PERJU D HE WS OF THE STATE Of
CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
EXECUTED ON fAn1iJ.(j3tfflJ; AT .1ibpJj, I [,,')4
~ATfI IOTY AHD STAHl
TREASURER (if applicable):
I HAVE USED ALL REASONABLE DILIGENCE IN PREPARING THIS STATEMENT AND TO THE BEST Of MY KNOWLEDGE THE INFORMATION
CONTAINED HEREIN AND IN THE ATTACHED SCHEDULES IS TRUE AND COMPLETE.
1 CERTIFY UNDER PENALTY OF PERJURY UNDER TH! LA, WS Of TH' STA TE Of CAUfaR"~H' faR'Ga'"2aLu, ~ CORRECT
EXECUTEaa~!!Im1!'lT JU;!!f'"'''' C'I/ BY. /~lt~
VERIFICA TlON
BY
I~HAruRf Of CAHDlDATf OR OfflCfHOlDERI
PAGE /l, OF 11
ALLOCATION PAGE
FORM 490
STATEMENT COVERS PERIOD
FROM THROUGH
1.0, NUMBER
LIST CONTRIBUTIONS AND INDEPENDENT EXPENDITURES TOTALING $100 OR MORE ADE FROM THE CANDIDATE'S OR OFFICEHOLDER'S PERSONAL
FUNDS TO SUPPORT OR OPPOSE OTHER OFFICEHOLDERS, CANDIDATES AND COMMITTEES. (SEE INSTRUCTIONS ON REVERSE.)
IND. NAME OF CANDIDATE. OFFICEHOLDER OR COMMITTEE CHECK ONE CUMULA TIVE
DATE AMOUNT TO DATE
EXP.
SUPPORT OPPOSE
CALENDAR YEAR
$
I~JI FISCAL YEAR
$
./J" ~'"
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) .................."."....."."..........".........., "......
$
.. tJ ..
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
this total to the Summary Page) .,.... ....,........ ........"......". ,.."..."".............,,...
$ ..~-
CAMPAIGN DISCLOSURE STATEMENT SUMMARY PAGE
FORM 490
(Amounts May Be Rounded To Whole Dollars)
:ONTRIBUTIONS RECEIVED
1. Monetary contributions. . . . . . . . . . . . . . . . . . . . .
2. Loansreceived......... ..... '" ............
3. SUBTOTAL CASH RECEIPTS. .... . .. .. . .. .....
4. Non-monetary contributions. . . . . . . . . .'. . . . . .
5. TOTAL CONTRIBUTIONS WITHOUT
ENFORCEABLE PROMISES. . . . . . . . . . . . . . . . . . .
6. Enforceable Promises (Except loan
guarantees, see Line 18 below). . . . . . . . . .. . . .
7. TOTAL CONTRIBUTIONS.. ... .. . ... . . ... ....
:XPENDITURES MADE
8. Payments..................:.... . . . . . . . . . .
9. Loans Made. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. SUBTOTAL................................
11. Accrued expenses (unpaid bills) . . . . . . . . . . . . .
12. TOTAL EXPENDITURES.....................
COLUMN A
Cumulative total
from previous period*
$ .MtJl. on
-0-
$ 346l IJ()
LINES 1 + 2
5/.!31LJ
.?J452.. ~
LINES 3 + 4
"0-
$ .:3-4.52..31LJ
LINES 5 + 6
$ J(J3D.~1LJ
-0"
J (J!JCJ. ~ILJ
'LINES 8 +9
/h.5~
$ /CJ4'1. ~
LINES 10 + 11
COLUMN B
Total this period from
attached schedules
$ 5f7.tJl)
SCHEDULE A, LINE 3
"'0.
SCHEDULE 8, LINE 7
$ 5=<;; ,a'J
LINES 1 + 2
-D...
SCHEDULE C, LINE 3
~2Z:a?
LINES 3 + 4
-0-
SCHEDIJLE r) . t"-!f: 7
$ !J~Z.OO
LINES 5 + 6
LU3"'/e4 .40'_
SCHEDULE E.lINE 5
-(j-
SCHEDULE EE, LINE 7
ze -if...t;. -40_
LINES 8 + 9
<1".59->
~'-ln..UV"'L', '--...~_
$ Z82'1. 81
LINES 10 + '1
PAGE ~
OF /'1
STATEMENT COVERS PERIOC
FROM THROUGH
J.D. NUMBER
COLUMN C
Cumulative to date
(ColumnsA + B)
1- .:592.3.00
-0.
~ _~9~.OO
LINES 1 + 2
5'1. ~
~n4.U
LINES 3 + 4
-0"
~ 09'1-4.3{p =
LINES 5 + 6
fCj,HOIII n ~nllLH I IN5= 7
L 3875.0'"
.. l)"
3B7!5.~
-()-
..--
$ g875. OJ,
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. Cashon hand at end ofrepo.-ting period (Lines 13 + 14 + 15-16above)
(If this 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). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , .
$ 23'1lJ. ~4
.522. t:J{)
-a-
Z8+4.~
~t 9-4-
ENDING CASH ON HAND SHOULD
NOT BE A NEGA TIVE AMOUNT
-0"
"0.
-()-
'-'
.
$
$
L
L
111 THRU 6130
SUMMARY FOR CANDIDATES IN BOTH A JUNE AND NOVEMBER ELECTION (See Instructions on Reverse)
21. CONTRIBUTIONS RECEIVED:
22. EXPENDITURES MADE:
7/1 TO DATE
t~4.~ j
3875:0' -
SCHEDULE A
MONETARY CONTRIBUTIONS RECEIVED
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PAGE -4
OF 1'/
STATEMENT COVERS PERIOD
FROM THROUGH
DATE
REC'D.
FULL NAME AND ADDRESS OF CONTRIBUTOR
(If COMMITTEE, IN ADDITION TO COMMITTEE'S NAME AND ADDRESS,
ENTER I,D, NUMBER OR,lf NO I.D, NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
EMPLOYER
AMOUNT
(If SELf.EMPLOYED, ENTER
NAME Of BUSINESS)
Occupation:
RECEIVED CUMULA TlVE
THIS PERIOD TO DA TE
Employer:
CALENDAR YEAR:
$
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:
$
Occupation:
CALENDAR YEAR:
$
Employer:
FISCAL YEAR:
$
CALENDAR YEAR:
$
Occupation:
Employer:
FISCAL YEAR:
$
SUBTOTAL $
-0-
SUMMARY
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 62Z,(J()
itemized). . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. TOTAL MONETARY CONTRIBUTIONS RECEIVED THIS PERIOD
(Line 1 + Line 2) Enter here and on Line 1, Column B of Summary Page. . . . . . . , . . , . . .
$ .5:a.M
SCHEDULE A
MONETARY CONTRIBUTIONS RECEIVED
(CONTINUATION SHEET)
FORM 490
(Amounts May Be Rounded To Whole Dollars)
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMIITEE:
DATE
REC'D.
(IF COMMITTEE, IN ADDITION TO COMMITTEE'S NAME AND ADDRESS,
ENTER I,D, NUMBER OR, IF NO I.D, NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
EMPLOYER
(IF SELF-EMPLOYED, ENTER
NAME OF BUSINESS
Occupation:
Employer:
OCCU patlon:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Em ployer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
SUBTOTAL
PAGE 5 OF /7
1.0, 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:
...
PART I: LOANS RECEIVED
DATE
REC'D.
FULL NAME AND ADDRESS OF LENDER
OCCUPA TION
EMPLOYER
INT, DUE
RATE DATE
(IF COMMITTEE, IN ADDITIDN TO COMMITTEE'S NAME AND ADDRESS,
ENTER 1.0, NUMBER OR, IF NO LD. NUMBER HAS BEEN ASSIGNED.
ENTER THE TREASURER'S NAME AND ADDRESS)
(IF SELf.EMPLOYED, ENTER
NAME OF BUSINESS)
OccupatiOn:
Employer:
Occupation:
Employer:
PAGE IJ
OF/7
STATEMENT COVERS PERIOD
FROM THROUGH
AMOUNT CUMU-
OF LOAN LA TIVE
TO DATE
CALENDAR YEAR
$
FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
SUBTOTAL
FULL NAME AND ADDRESS OF GUARANTOR
OCCUPATION
EMPLOYER
(IF SELF.EMPLOYED, ENTER
NAME OF BUSINESS)
Occupation:
(IF COMMITTEE. IN ADDITION TO COMMITTEE'S NAME AND ADDRESS,
ENTER I.D, NUMBER OR,IF NO I.D, NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESSl
: NAME OF LENDER
Employer:
: NAME OF LENDER
Occupation:
Employer:
SUBTOTAL
DO NOT CARRY THIS AMOUNT TD THE
SUMMARV BELOW. ENTER ON LINE 18
OF THE SUMMARV 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 $100 REPAID, FORGIVEN OR PAID BY A THIRD PARTY
(not previously itemized) (If forgiven or paid by a third party, also enter
amount on Line 2 of the summary section of Schedule A). . , . . . . . . . . . . . . . . . . . . . . . . .
6. TOTAL LOANS REPAID, FORGIVEN OR PAID BY A THIRD PARTY THIS PERIOD
(Line 4 + 5). . . . . . . . . . . . . . . . . . , . . . . . . . . . , . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . .
7. NET CHANGE THIS PERIOD (Subtract Line 6 from Line 3)
Enter the difference here and on Line 2, Column B of Summary Page. . . . . . . . . . . . . . .
(a)
::::$;~:.~~~~f:~lW:::X*'.}~~f:f~
.~~::m."....,.an,~m"::<
:~.1~11
.fk>~".BilW'm .~'<:,..:<l
'::-:::..:!;<:::x '.~:::::.,: ~v;:;..:::::::x~
....~..........x~:...,>>...... . ..~........~:::-.%~
............Y?...... .;.:-:Y>:....
$ -0"
AMOUNT
GUARANTEED
CUMU-
lA TIVE
TO DATE
CALENDAR YEAR
$
THIS
PERIOD
FISCAL YEAR
$
CALENDAR YEAR
$
FISCAL YEAR
$
(b)
$ -0-
$
-0-
"0-
-a --
(May be neg-
ative figurei
SCHEDULE B -- LOANS RECEIVED (PART 1)
(CONTINUATION PAGE)
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PAGE
7
OF /1
STATEMENT COVERS PERIOD
FROM THROUGH
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
..-
PART I: LOANS RECEIVED
DATE
RE('D
FULL NAME AND ADDRESS OF LENDER
(IF COMMITIEE.IN ADDITION TO COMMITIEE'S NAME AND ADDRESS,
ENTER I.D, NUMBER OR, IF NO I.D, NUMBER HA. BEEN ASSIGNED.
ENTER THE TREASURER'S NAME AND ADDRESS)
FUll NAME AND ADDRESS OF GUARANTOR
(IF COMMITIEE.IN ADDITION TO COMMITIEE'S NAME AND ADDRESS.
ENTER I.D, NUMBER OR, IF NO /.D, NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
: NAME OF lENDER
: NAME Of lENOiR
: NAME Of lENDER
: NAME Of lENDER
OCCUPA TION
EMPLOYER
(If Sll ,-EMPlOYED, ENTER
NAME m BUSINESS)
Occu~allun ,
Employer:
Occupation _
Employer:
Occupation:
Employer:
SUBTOTAL
1.0_ NUMBER
INT, DUE AMOUNT
RATE DA TE OF LOAN
CUMU-
LA TIVE
TO DATE
CALENDAR YEAR:
S
fiSCAL YEAR:
S
CALENDAR YEAR:
S
fiSCAL YEAR:
S
CALENDAR YEAR:
fiSCAL YEAR:
S
OCCUPA TION
EMPLOYER
(If SELf-EMPLOYED, ENTER
NAME OF BUSINE SS)
Occupation:
AMOUNT
GUARANTEED
THIS CUMU-
PERIOD LATIVE
TO DATE
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
(b)
SUBTOTAL
.. Q..
CALENDAR YEAR:
S
fiSCAL YEAR:
S
CALENDAR YEAR:
fiSCAL YEAR:
S
CALENDAR YEAR:
S
fiSCAL YEAR:
CALENDAR YEAR:
S
fiSCAL YEAR:
S
SCHEDULE B -- LOANS RECEIVED (PART 2)
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PART 2: LOAN REPAYMENTS MADE, LOANS FORGIVEN OR
DATE OF
REPAY-
MENT OR
FORGIVE-
NESS
FULL NAME OF LENDER
INT
RA TE (IF FORGIVEN*
CHANGED)
AMOUNT REPAID
OR FORGIVEN ON
PRINCIPAL (DO NOT
INCLUDE PA YMENT
OF INTEREST)
DATE OF
ORIGINAL
LOAN
* 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 INTEREST PALO THIS PERIOD, ALSO ENTER
ON LINE 3 OF THE SUMMARY SECTION OF SCHEDULE E,
DO NOT CARRY THIS TOT Al TO THE SCHEDULE B SUMMARY
PAGE g
OF /'7
STATEMENT COVERS PERIOD
FROM THROUGH
;
1.0, NUMBER
OUTSTANDING
PRINCIPAL
TOTAL INTEREST PAID $
THIS PERIOD
INTEREST
PAID**
(d)
SCHEDULE B -- LOANS RECEIVED (PART 3)
ANNUAL REPORT OF OUTSTANDING LOANS RECEIVED
FORM 490
PAGE '1
OF /1
(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
TOTAL
$ -0-
(NOTE: THIS TOTAL
SHOULD BE THE SAME
AMOUNT AS ENTERED
ON LINE 2, COLUMN C
Of THE SUMMARY PAGE)
SCHEDULE C
NON-MONETARY CONTRIBUTIONS RECEIVED
FORM 490
(Amounts May Be Rounded To Whole Dollars)
DATE
REC'D.
FULL NAME AND ADDRESS
OF CONTRIBUTOR
(IF COMMITTEE, IN ADDITION TO COMMITTEE'>
NAME AND ADDRESS, ENTER 1.0 NUMBER
OR, IF NO 1.0. NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
(IF SELF-EMPLOYED, ENTER
NAME OF BUSINESS)
Occupation:
EMPLOYER
DESCRIPTION OF
GOODS OR SERVICES
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
SUBTOTAL
SUMMARY
1. NON-MONETARY CONTRIBUTIONS OF $100 OR MORE RECEIVED THIS PERIOD... ... . . $
2, NON-MONETARY CONTRIBUTIONS UNDER $100 RECEIVED THIS PERIOD (Not
itemized). . _ . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . , _ . . . . . . . . . . . . . . . . . . . . . . . _ . . . , . . . . . _
3. TOTAL NON-MONETARY CONTRIBUTIONS RECEIVED THIS PERIOD
(Line 1 + Line 2) Enter here and on Line 4 Column B of Summary Page. . . . . _ . . . . . . . . . $
PAGE /0 OF /'7
.
STATEMENT COVERS PERIOD
FROM THROUGH
10, NUMBER
FAIR CUMU-
MARKET LA TIVE
VALUE AMOUNT
RECEIVED
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:
$
$ ..(j..
...t).
-(J ..
-tJ-
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 B, NOT Schedule D.
(Amounts May Be Rounded To Whole Dollars)
NAME OF CAND DATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
,.
PAGE /1 OF 17
10. NUMBER
AMOUNT CUMU-
PAID LATIVE
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'"
FULL NAME AND ADDRESS
OF CONTRIBUTOR
(IF COMMITTEE, IN AODITION TO COMMITTEE'S
NAME AND ADDRESS, ENTER I.D NUMBER
OR, IF NO I.D. NUMBER HAS BEEN ASSIGNED,
ENTER THE TREASURER'S NAME AND ADDRESS)
DATE
REeD,
AMOUNT
PROMISED
THIS PERIOD
EMPLOYER
(IF SELF-EMPLOYED, ENTER
NAME OF BUSINESS)
Occupa{lun:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
Occupation:
Employer:
(a)
SUBTOTAL $
-0-
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 $100 OR MORE RECEIVED THIS
PERIOD (Column (b)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . _ _ . . . . . . _ . . . . . . . . . . .
5. PAYMENTS ON PROMISES UNDER $100 RECEIVED THIS
PERIOD (Not itemized). . . . . . . . . . . . . . . .. . _ . . . . . . . _ . . . . _ . . _ _ . . . _ . . . . . _ . . . . _ _ . .. . _ .
(Also enter on Line 2 ofthe 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-
(May be neg-
atlv~ figure,
SCHEDULE E
PAYMENTS AND CONTRIBUTIONS (OTHER THAN LOANS) MADE
FORM 490
PAGE /2.. OF 17
STATEMENT COVERS PERIOD
(Amounts May Be Rounded To Whole Dollars)
I.D. NUMBER
...
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
"W -- 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 PA YEE, CREDITOR OR
RECIPIENT OF CONTRIBUTION
(IF COMMITTEE, IN ADDITION TO COMMITTEE'S
NAME AND ADDRESS, ENTER 1.0. NUMBER
OR, IF NO 1.0, NUMBER HAS BEEN ASSIGNED, ENTER THE
TREASURER'S NAME AND ADDRESS)
AMOUNT
PAID
CODE OR DESCRIPTION OF PA YMENT
t717e tlpa<<~
~~ "'tmter'~!I
(jzl;n , CA .J
.:Jr~ ~ .;il()ytr~
~~ ,O/~te'ie"y
/meY'tLe
.a. ~ ~
fit , C74
~u.se Santana.
,4 /)??V'~
"Of
K
1 99-4.7()
F
" 21./2-
J.I 33.58
F ~,/j7
/~.~
k.
SUBTOTAL $
SUMMARY
1. PAYMENTSOF$1000RMOREMADETHISPERIOD $
(Include all Schedule E subtotals) ....,.,.,.,..........,......................,...,......."....,......,.,...........,..,..,....
U/~.95
.aa .45
2. PAYMENTS UNDER $100 THIS PERIOD (Not itemized) ...............................................................
3. TOTAL INTEREST PAID THIS PERIOD ON OUTSTANDING LOANS
(Schedule B, Part 2, Column (d)) ....""."..,,,,,......,...,,.....,,........,,.
.0.
~O-
4. TOTAL ACCRUED EXPENSES PAID THIS PERIOD (Not itemized) (Schedule F, Line 4).............."...
5. TOTAL PAYMENTS THIS PERIOD (Line 1 + 2 + 3 + 4) Enter here and on Line 8, Column B of
Summary Page ..........""."".................",,,.....,,..,..,,........,,.....,,.....,,...,,......,,..............,...."........,. $ 28+f.~tL
SCHEDULE E
PAYMENTS AND CONTRIBUTIONS (OTHER THAN LOANS) MADE
(CONTINUATION SHEET)
FORM 490
{Amounts May Be Rounded To Whole Dollars}
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
^'
PAGE /~ OF /1
STATEMENT COVERS PERIOD
FROM THROUGH
I.D. NUMBER
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" -- LITERATURE
"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 SE RVICES
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 1.0. NUMBER
OR,IF NO 1.0. NUMBER HAS BEEN ASSIGNED, ENTER THE
TREASURER'S NAME AND ADDRESS)
AMOUNT
PAID
CODE OR
DESCRIPTION OF PAYMENT
o
~ t!F ~~n-
C/J1)trtbutfo1r..,
1"".00
#
1()(J.(t)
q
,c
6J.
t:
1~2.()()
53. -42-
SUBTOTAL
$ '12..4.03
SCHEDULE EE
LOANS MADE TO OTHERS
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PAGE /4
OF /7
STATEMENT COVERS PERIOD
FROM THROUGH
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
-
!.D. NUMBER
DATE
OF
LOAN
FULL NAME AND ADDRESS OF RECIPIENT
INTEREST
RATE
DUE DATE
AMOUNT
CUMULA TIVE
AMOUNT
SUBTOTAL
$
. O.
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
MENT OR ORIGINAL
FORGIVE- LOAN
NESS
FULL NAME OF
RECIPIENT OF LOAN
INT.
RA TE (IF
CHANGED)
FORGIVEN/PAID BY THIRD PARTY AMOUNT REPAID OUT-
OR FORGIVEN ON STANDING
FORGIVEN lOAN,S: Enter "Forgiven" Also PRINCIPAL (DO NOT PRINCIPAL
itemize for Iven loans on Schedule E. INCLUDE RECEIPT
PAYMENT BY THIRD PARTY: Enter name OF INTEREST)
INTEREST
RECEIVED*
SUBTOTAL
$
"'0-
(a)
*TOTAl All INTEREST RECEIVED THIS PERIOD, ALSO ENTER
ON LINE 3 OF THE SUMMARY SECTION 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. . . . . . . . . . . . . . . .
SCHEDULE EE - LOANS MADE TO OTHERS {PART 3}
ANNUAL REPORT OF OUTSTANDING LOANS MADE
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PAGE /5 OF /7
STATEMENT COVERS PERIOD
FROM THROUGH
10. 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 17
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE'
...
STATEMENT COVERS PERIOD
FROM THROUGH
..-
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 "r.) 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
"5. -- SURVEYS, SIGNATURE GATHERING, DOOR-TO-DOOR
SOLICITATIONS
'T' -- FUNDRAlslNG 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 PAYEE, CREDITOR
OR RECIPIENT OF CONTRIBUTION
(IF COMMITTEE, 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
SUBTOTAL -0-
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 PERIOD ..............................................
.0"
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) ..........,........,............................ ........ ...........................
5. NET CHANGE THIS PERIOD (Subtract Line 4 from Line 3) Enter difference here and on
Line 11, Column B of Summary Page .....................................................................
/6,,09
</6.59 >
$ ...~
(May be
negative figure)
SCHEDULE G
MISCELLANEOUS INCREASES TO CASH
FORM 490
(Amounts May Be Rounded To Whole Dollars)
PAGE /1 OF /1
STATEMENT COVERS PERIOD
FROM THROUGH
""
NAME OF CANDIDATE OR OFFICEHOLDER AND CONTROLLED COMMITTEE:
to
DATE
REC'D,
FULL NAME AND ADDRESS OF SOURCE
(IF COMMITTEE, IN ADDITION TO COMMITTEE'S
NAME AND ADDRESS, ENTER I.D NUMBER
OR, If NO LD, NUMBER HAS BEEN ASSIGNED.
ENTER THE TREASURER'S NAME AND ADDRESS)
DESCRIPTION OF ADJUSTMENT
SUBTOTAL
SUMMARY
1. INCREASES TO CASH OF $100 OR MORE THIS PERIOD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. INCREASES TO CASH UNDER $100 THIS PERIOD (Not itemized). . . . . . . . . . . . . . . . . . . . . .
3. TOTAL OF ALL INTEREST RECEIVED THIS PERIOD ON LOANS MADE TO OTHERS
(Schedule EE, Part 2 (b)) . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . , . . . . , . . . . . . . . . . . . . . . . . . . . .
4. TOTAL MISCELLANEOUS INCREASES TO CASH THIS PERIOD
(Line 1 + 2 + 3) Enter here and on Line 15 of Summary Page. , . . . . . . . . . . . . . . . . . . . . .
ID, NUMBER
"06 'J I
AMOUNT OF
INCREASE
TO CASH
$
"0-
$
-(!j"
"I)-
-0-
$
"'0-