Campaign Finance Report
DUE ON July 15, 1999
(For the period of November 4, 1998 through July 13, 1999)
Candidates for : |
STATE OFFICE GENERAL ASSEMBLY COUNTY OFFICE |
Please TYPE:
Candidate Information
Full Name of Candidate ____________________________________________________________________________
First Middle Last Nick Name (if any)Campaign Information
Campaign Name _________________________________________________________________________________
Address ________________________________________________________________________________________
Town__________________________________________________ State __________ Zip Code _________________
Telephone ______________________________________ Party Affiliation ____________________________________
Office Sought ____________________________________________________________________________________
I hereby certify that the information in this campaign finance disclosure report is true to the best of my knowledge, information and belief:
___________________ _________________________________________________________________________
date Candidate’s Signature
___________________ _________________________________________________________________________
date Treasurer’s Signature
Campaign Finance Report
DUE ON July 15, 1999
(For the period of November 4, 1998 through July 13, 1999)
POLITICAL COMMITTEES OR POLITICAL PARTIES |
Please TYPE:
PARTY OR COMMITTEE Information
Name of Contact Person______________________________________________________________________________
First Middle Last Nick Name (if any)Name of Party or Committee __________________________________________________________________________
Address __________________________________________________________________________________________
Town__________________________________________________ State __________ Zip Code ___________________
Telephone ______________________________________
I hereby certify that the information in this campaign finance disclosure report is true to the best of my knowledge, information and belief:
___________________ ________________________________________________________________________
date Treasurer’s Signature
CAMPAIGN FINANCE DISCLOSURE FORM
page _______ of ______ pages(November 4, 1998 through July 13, 1999)
REPORT SUMMARY PART I |
Date of this report ________________ Name of Candidate, Party or Committee___________________________________________
Total Amount Carried Forward From 1998 Campaign: $___________________________
TOTAL OF ALL CONTRIBUTIONS OVER $100.00 |
|||
FOR THIS REPORT |
CAMPAIGN TO DATE |
||
IN-STATE (Vermont Residents) |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
OUT OF STATE (NON-Vermont Residents/Unknown) |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
TOTAL CONTRIBUTIONS OVER $100.00 |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
TOTAL OF ALL CONTRIBUTIONS $100.00 or LESS |
|||
FOR THIS REPORT |
CAMPAIGN TO DATE |
||
IN-STATE (Vermont Residents) |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
OUT OF STATE (NON-Vermont Residents/Unknown) |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
TOTAL CONTRIBUTIONS $100.00 or LESS |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
Part I of Summary of Contributions continued on next page.
CAMPAIGN FINANCE DISCLOSURE FORM
page _______ of ______ pages(November 4, 1998 through July 13, 1999)
REPORT SUMMARY PART I continued |
Date of this report ________________ Name of Candidate, Party or Committee___________________________________________
TOTAL DEBT or OTHER OBLIGATIONS DISCHARGED or FORGIVEN |
|||
FOR THIS REPORT |
CAMPAIGN TO DATE |
||
IN-STATE (Vermont Residents) |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
OUT OF STATE (NON-Vermont Residents/Unknown) |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
TOTAL DISCHARGED DEBT and OBLIGATIONS |
AMOUNT: NUMBER: |
$____________________; _____________________;
|
$____________________ _____________________ |
| GRAND TOTAL OF ALL CONTRIBUTIONS (including DISCHARGED DEBT and OBLIGATIONS) |
||
FOR THIS REPORT |
CAMPAIGN TO DATE |
|
AMOUNT |
$__________________; |
$_________________ |
NUMBER |
___________________; |
___________________ |
CAMPAIGN FINANCE DISCLOSURE FORM
page _______ of ______ pages(November 4, 1998 through July 13, 1999)
REPORT SUMMARY PART II |
Date of this report ________________ Name of Candidate, Party or Committee___________________________________________
EXPENDITURES |
Total AMOUNT of All Expenditures
FOR THIS REPORT $_______________; CAMPAIGN TO DATE $_______________
AMOUNT of CONTRIBUTIONS or LOANS by CANDIDATE |
Amount of CONTRIBUTIONS or LOANS by candidate to campaign this report: $__________________
CAMPAIGN FINANCE DISCLOSURE FORM page _______ of ______ pages
(November 4, 1998 through July 13, 1999)
CONTRIBUTIONS OVER $100.00 |
Date of this report ________________ Name of Candidate, Party or Committee___________________________________________
| Name of Contributor _________________________________________________________________________________________ (Natural Person) Last First Middle Name or Initial (if any)Name of Contributor (Political Committee, Political Party or Other Single Source) ______________________________________________________________Town and State of Residence___________________________________________________________________________________ Address____________________________________________________________________________________________________ Address_______________________________________________________________State ___________ Zip __________________ Date of Total Amount of Contribution ________________ Amount $__________________ Contributor’s Contributions to Date $_________________ If In-Kind Contribution, Please Describe__________________________________________________________________________ |
| Name of Contributor _________________________________________________________________________________________ (Natural Person) Last First Middle Name or Initial (if any)Name of Contributor (Political Committee, Political Party or Other Single Source) ______________________________________________________________Town and State of Residence___________________________________________________________________________________ Address____________________________________________________________________________________________________ Address_______________________________________________________________State ___________ Zip __________________ Date of Total Amount of Contribution ________________ Amount $__________________ Contributor’s Contributions to Date $_________________ If In-Kind Contribution, Please Describe__________________________________________________________________________ |
| Name of Contributor
_________________________________________________________________________________________ (Natural Person) Last First Middle Name or Initial (if any)Name of Contributor (Political Committee, Political Party or Other Single Source) ______________________________________________________________Town and State of Residence___________________________________________________________________________________ Address____________________________________________________________________________________________________ Address_______________________________________________________________State ___________ Zip __________________ Date of Total Amount of Contribution ________________ Amount $__________________ Contributor’s Contributions to Date $_________________ If In-Kind Contribution, Please Describe__________________________________________________________________________ |
Total AMOUNT of contributions over $100.00 on this page: $ ________________________
Note: "Full NAME" means an individual’s full name, middle name or initial, if any, and full legal last name, making the identity of the person who made the contribution apparent by unambiguous reference.
CAMPAIGN FINANCE DISCLOSURE FORM page _______ of ______ pages
(November 4, 1998 through July 13, 1999)
DEBT OR OTHER OBLIGATIONS DISCHARGED OR FORGIVEN BY CREDITOR |
Date of this report ________________ Name of Candidate, Party or Committee___________________________________________
| Date of Discharge or Forgiveness__________________________________________ Manner of Discharge or Forgiveness_____________________________________________________________________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ___________ Zip _______________________ Total Amount of Debt or Other Obligation Discharged or Forgiven by Creditor Campaign to Date $___________________________ |
| Date of Discharge or Forgiveness__________________________________________ Manner of Discharge or Forgiveness_____________________________________________________________________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ___________ Zip _______________________ Total Amount of Debt or Other Obligation Discharged or Forgiven by Creditor Campaign to Date $___________________________ |
| Date of Discharge or Forgiveness__________________________________________ Manner of Discharge or Forgiveness_____________________________________________________________________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ___________ Zip _______________________ Total Amount of Debt or Other Obligation Discharged or Forgiven by Creditor Campaign to Date $___________________________ |
| Date of Discharge or Forgiveness__________________________________________ Manner of Discharge or Forgiveness_____________________________________________________________________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ___________ Zip _______________________ Total Amount of Debt or Other Obligation Discharged or Forgiven by Creditor Campaign to Date $___________________________ |
Total AMOUNT of Debts or Obligation Discharged or Forgiven on this page: $ _________________________
NOTE: Forgiven debt must be included as a contribution on Report Summary PART I.
CAMPAIGN FINANCE DISCLOSURE FORM page _______ of ______ pages
(November 4, 1998 through July 13, 1999)
DEBT OR OTHER OBLIGATION INCURRED |
Date of this report ________________ Name of Candidate, Party or Committee__________________________________
| Amount of Debt or Other Obligation Incurred $____________________________ Date Incurred _____________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ____________ Zip ______________________ Purpose of Debt or Other Obligation _____________________________________________________________________________ |
| Amount of Debt or Other Obligation Incurred $____________________________ Date Incurred _____________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ____________ Zip ______________________ Purpose of Debt or Other Obligation _____________________________________________________________________________ |
| Amount of Debt or Other Obligation Incurred $____________________________ Date Incurred _____________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ____________ Zip ______________________ Purpose of Debt or Other Obligation _____________________________________________________________________________ |
| Amount of Debt or Other Obligation Incurred $____________________________ Date Incurred _____________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ____________ Zip ______________________ Purpose of Debt or Other Obligation _____________________________________________________________________________ |
| Amount of Debt or Other Obligation Incurred $____________________________ Date Incurred _____________________ Creditor’s Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address__________________________________________________________State ____________ Zip ______________________ Purpose of Debt or Other Obligation _____________________________________________________________________________ |
Total AMOUNT of Debts or Obligation Incurred on this page: $ _________________________
CAMPAIGN FINANCE DISCLOSURE FORM page _______ of ______ pages
(November 4, 1998 through July 13, 1999)
EXPENDITURES |
Date of this report ________________ Name of Candidate, Party or Committee___________________________________________
| Amount of Expenditure $________________________ Date of
Expenditure_______________________ To Whom Paid______________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address____________________________________________________________State ___________ Zip _____________________ Purpose of Expenditure________________________________________________________________________________________ |
| Amount of Expenditure $________________________ Date of Expenditure_______________________ To Whom Paid______________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address____________________________________________________________State ___________ Zip _____________________ Purpose of Expenditure________________________________________________________________________________________ |
| Amount of Expenditure $________________________ Date of Expenditure_______________________ To Whom Paid______________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address____________________________________________________________State ___________ Zip _____________________ Purpose of Expenditure________________________________________________________________________________________ |
| Amount of Expenditure $________________________ Date of Expenditure_______________________ To Whom Paid______________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address____________________________________________________________State ___________ Zip _____________________ Purpose of Expenditure________________________________________________________________________________________ |
| Amount of Expenditure $________________________ Date of Expenditure_______________________ To Whom Paid______________________________________________________________________________________________ Address____________________________________________________________________________________________________ Address____________________________________________________________State ___________ Zip _____________________ Purpose of Expenditure________________________________________________________________________________________ |
Total AMOUNT of expenditures on this page: $ ____________________