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CAMPAIGN DISCLOSURE REPORT FOR THE PERIOD ENDING: NAME OF CANDIDATE OR COMMITTEE -(Revsed 021201) REPORT OF RECEIPTS AND DISBURSEMENTS Page 1 For an Authorized Committee (Summary Page) 1. Name of Candidate or Committee (in Full) 2. Report Identification No. Address (number and street) 3. Is this report an amendment Yes City, Island and Zip Code No January Semi Annual Report Primary Election Report June Semi Annual Report General Election Report Special Election Report Runoff Election Report 4. Covering Period through This Period Calendar Year-to-Date 5. Beginning Cash on Hand Balance 6. Totat Contributions, loans & Receipts (Form 1) 7. Total Operating Expenditures (Form 2) 8. Ending Cash on Hand Balance 9. Debts and Obligations a. Total loan amounts (Form 3) b. Tota! Contributions Receivable (Form 4) c. Total Expenditures Payable (Form 5) | certify that | have examined this Report and to the best of my knowledge and belief it is true, correct and complete. Signature of Candidate or Treasurer : Date “ NOTE * Submission of false, erroneous, or incomplete information may subject the person signing this report to the penalties of 18 V.I.C. section 9114. Detailed Summary Page of Receipts and Disbursement _ Name of Candidate or Committee (in Full) Receipts 10, CONTRIBUTIONS, LOANS & RECEIPTS This Period a. Individuals/Persons other than political committees Year-to-Date (Form 1 - A) Political Party Committees (Form 1 - B) Other Political Committees (such as PAC's) (Form 1 - C) The Candidate (Form 1 - D) Contributions from other Authorized Committees (Form 1 - E) Loans made or guaranteed by the Candidate (Form 1 - F) All other loans (Form 1 - F) Other Receipts (Form 1 - G) TOTAL CONTRIBUTIONS, LOANS & RECEIPTS 11. DISBURSEMENTS b. Operating Expenditures (Form 2 - A) Other Disbursements (Form 2 - B) TOTAL DISBURSEMENTS 12. Cash on Hand last Reporting Period Cash on Hand this Reporting Period | certify that | have examined this Report and to the best of my knowledge and belief it is true, correct and complete. Signature of Candidate or Treasurer Date “ NOTE “* Submission of false, erroneous, or incomplete information may subject the person signing this report to the penalties of 18 V.1.C. section 914. CONTRIBUTIONS INDIVIDUALS/PERSONS OTHER THAN POLITICAL COMMITTEES (FORM 1-A) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Contributors: Full Name Mailing address Principal Place of Business Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Full Name Mailing address Principal Place of Business Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Full Name Mailing address Principal Place of Business Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Fuli Name Mailing address Principal Place of Business Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) “*NOTE** Duplication of this form is allowed if there are more than four (4) contributors CONTRIBUTIONS POLITICAL PARTY COMMITTEES (FORM 1-B) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Contributors: Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) **NOTE™ Duplication of this form is allowed If there are more than four (4) contributors CONTRIBUTIONS OTHER POLITICAL COMMITTEES (such as PAC's) (FORM 1-C) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Contributors: Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) “*“NOTE* Duplication of this form ts allowed if there are more than four (4) contributors (Please attach copies of checks, money orders or receipts for your back-up information) CONTRIBUTIONS THE CANDIDATE (FORM 1-D) Name of Candidate or Committee (in Full) Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution ““NOTE™ Duplication of this form is allowed if necessary CONTRIBUTIONS OTHER AUTHORIZED COMMITTEES (FORM 1-E) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Contributors: Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) ““NOTE* Duplication of this form is allowed if necessary CONTRIBUTIONS LOANS MADE OR GUARANTEED BY THE CANDIDATE (FORM 4-F) (Please attach copies of loan agreements, promissory notes and /or other relavant documents) Name of Candidate or Committee (in Full) Loans: Name of Lender Loan amount Loan terms of repayment Loan period Date of Loan Aggregate amount of Loan (Year-to-Date) Name of Lender Loan amount Loan terms of repayment Loan period Date of Loan Aggregate amount of Loan (Year-to-Date) ALL OTHER LOANS Name of Lender Loan amount Loan terms of repayment Loan period Date of Loan Aggregate amount of Loan (Year-to-Date) Name of Lender Loan amount Loan terms of repayment Loan period Date of Loan Aggregate amount of Loan (Year-to-Date) “*NOTE* Duplication of this form is allowed if necessary CONTRIBUTIONS OTHER RECEIPTS (FORM 1-G) (Piease attach one (1) original document for proof of event (such as a food sale ticket) for your back-up info.) Name of Candidate or Committee (in Full) Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 1 Location and Type of Event Oate of Event Amount of Ticket Sales Amount from Mass Coltections Total 2 Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 3 Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 4 Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 5 PAGE TOTAL GRAND TOTAL “NOTE” Duplication of this form is allowed if necessary TOTAL SUM OF CONTRIBUTIONS, LOANS & RECEIPTS (FORM 1) Name of Candidate or Committee (in Full) It is hereby certified that during the period to __, the total sum of was contributed to the candidate or committee identified above, and that the persor or persons making the contribution(s) are listed regardiess of the amount contributed. It is hereby certified that during the period to 7 ,_ the total sum of was Loaned to the candidate or committee identified above, and that the person or persons making the l!oan(s) are listed regardless of the amount loaned. It is hereby certified that during the period to | , the total sum of was received by the candidate or committee identified above, and that the events or fundraising activities where these receipts were collected are listed regardless of the amount received Signature of Candidate or Treasurer ITEMIZED EXPENDITURES (FORM 2-A) (Please attach copies of checks, invoices, receipts and all documents to support all expenditures) Name of Candidate or Committee (in Full) Full Name, Malling Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 1 Full Name, Malling Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 2 Full Name, Malling Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 3 Full Name, Mailing Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 4 Full Name, Mailing Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 5 Full Name, Malling Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 16 PAGE TOTAL GRAND TOTAL “*NOTE** Duplication of this form is allowed if necessary OTHER DISBURSEMENTS (FORM 2-B) (Please attach copies of checks, invoices, receipts and atl documents to support all expenditures) Name of Candidate or Committee (in Full) Full Neme, Malting Address and Zip Cade Date of Disbursement Purpose of Disbursement Amount of Olsbursment 1 Futi Name, Malling Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 2 Full Name, Malling Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 3 Fuli Name, Malling Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 4 Pull Name, Malling Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 5 Full Name, Malling Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 8 PAGE TOTAL GRAND TOTAL *“*NOTE™ Duplication of this form is allowed if necessary TOTAL SUM OF EXPENDITURES & OTHER DISBURSMENTS (FORM 2) Name of Candidate or Committee (in Full) It is hereby certified that during the period to , the total sum of was expended in accordance with the provision of Title 18 Section 905 of the Virgin Islands Code and that each expenditure was reported regardless of the amount expended. Signature of Candidate or Treasurer (Please attach copies of checks, Invoices, receipts and all supporting documents) DEBTS AND OBLIGATIONS CONTRIBUTIONS RECEIVABLE Name of Candidate or Committee (in Full) due to the Committee Date of Receivable Circumstance and conditions of the Recelvable Amount of Recelvabie 1 Full and Complete Identification of Recelvables due to the Committee Date of Receivable Clecumstance and conditions of the Recelvable Amount of Receivable 2 Full and Comptete Identification of Receivabies due to the Committee Date of Receivabie Circumstance and conditions of the Recelvable Amount of Recelvable 3 Full and Compiete Identification of Recetvables due to the Committee Date of Receivable Circumstance and conditions of the Receivable Amount of Recelvable 4 Full and Complete identification of Receivables __tue to the Committee Date of Receivable Circumstance and conditions of the Recelvable Amount of Recelvable 5 Full and Complete identification of Recelvables due to the Committee Date of Recelvable Chkeumstance and conditions of the Recelvable Amount of Recelvable 16 |_PAGE TOTAL GRAND TOTAL **NOTE** Duplication of this form Is allowed if necessary DEBTS AND OBLIGATIONS Page 15 EXPENDITURES PAYABLE (Please attach copies of checks, invoices, receipts and all supporting documents) Name of Candidate or Committee {in Full) Pull and Complete Kientification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amount of Payable 1 Full and Comptete Identification of Payable due : from the Committee Date of Payabte Circumstance and conditions of Payable Amount of Payable 2 Full and Complete identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amaunt of Payable 3 Full and Complete identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amaunt of Payable 4 Puli and Complete Identification of Payable due from the Cominittee Date of Payable Circumstance and conditions of Payable Amount of Payable 5 Full ant Compitete identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amount of Payable 6 PAGE TOTAL “*NOTE™ Duplication of this form is allowed if necessary NON-MONETARY CONTRIBUTIONS (ITEMS) Page 16 (Please attach copies of invoices, receipts and all supporting documents) Name of Candidate or Committee (in Full) Full Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 4 Fuli Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Valua of Contribution 2 Full Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 3 Fult Name, Malling Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 4 Fut] Name, Malling Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 5 Full Maliing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution iG PAGE TOTAL GRAND TOTAL ““NOTE** Duplication of this form is allowed if necessary sanannaseNOTE**seaesease DIL EASE ENCLOSE COPIES OF BANK STATEMENTS, RECIEPTS, INVOICES, PROMISSORY NOTE, AND OTHER SUPPORTING DOCUMENTATION. DO NOT WRITE ON THIS PAGE, ELECTION USE ONLY!!! RECEIVED FROM NAME OF CANDIDATE OR COMMITTEE REPORTING PERIOD DATE ELECTION OFFICIAL'S SIGNATURE