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SEEC FORM 30 Page 1 of 16 Itemized Campaign …

Method of Contribution: fundraising event listed in Section J1? No Cash Personal Check Money Order Credit/Debit Card

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Text of SEEC FORM 30 Page 1 of 16 Itemized Campaign …

(mm/dd/yyyy) PENALTY FOR FALSE STATEMENT IS PUNISHABLE BY FINE NOT TO EXCEED $1,000, OR IMPRISONMENT FOR NOT MORE THAN ONE YEAR, OR BOTH. 6. OFFICE SOUGHT (Complete only if Candidate Committee) 5. ELECTION DATE 8. CANDIDATE NAME (Complete only if Candidate or Exploratory Committee) First MI Last Suffix 4. TREASURER ADDRESS Street Address City State Zip Code 7. DISTRICT NUMBER 1. NAME OF COMMITTEE 3. TREASURER NAME First MI Last Suffix 9. TYPE OF REPORT (Check One Box) 10. PERIOD COVERED Beginning Date Ending Date thru 11. CERTIFICATION I hereby certify and state, under penalties of false statement, that all of the information set forth on this Itemized Campaign Finance Disclosure Statement for the period covered is true, accurate and complete. TREASURER OR DEPUTY TREASURER (SIGNATURE) PRINT NAME OF SIGNER DATE (mm/dd/yyyy) (if applicable) SEEC FORM 30 Itemized Campaign Finance Disclosure Statement CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION Revised January 2012 Do Not Mark in This Space For Official Use Only COVER PAGE Page 1 of 16 2. TYPE OF COMMITTEE Candidate Committee Exploratory Committee January 10 filing April 10 filing July 10 filing October 10 filing 7th day preceding primary 30 days following primary 7th day preceding election 7th day preceding special election Initial Itemized Statement accompanying application for Public Grant Additional Itemized Statement in further support of application for Public Grant Post Primary Itemized Statement accompanying request for General Election Grant Deficit Termination Amendment to Type of Report: Supplemental Statement (Specify Type) Primary Election Declaration of Excess Expenditures (Specify Type) Primary Election SEEC FORM 30 Itemized Campaign Finance Disclosure Statement CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION Revised January 2012 SUMMARY PAGE TOTALS NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) TYPE OF REPORT 12. Balance on hand from day committee was formed 13. Balance on hand at the beginning of Reporting Period 14. Contributions Received from Individuals (Sections A and B) 15. Receipts from Other Committees (Sections C1 and C2) 16. Other Monetary Receipts (Sections D through I) 18. Total Monetary Receipts (add totals for Lines 14 through 17) 19. Subtotals (add totals in Line 13 + 18 in Column A; and in Line 12 + 18 in Column B) 20. Expenses Paid by Committee (Section N) 21. Balance on hand at close of Reporting Period (Subtract Line 20 from Line 19 in both Columns) 23. In-Kind Contributions Received (Section K) 24. Refundable Deposit to Telephone Company (Section L) 26a. + Loans Received (Section D) 26b. + Interest and Penalties on Loan 26c. - Payments on Loan 26d. Total Outstanding Loan Amount 27. Campaign Expenses Paid by Candidate (Section O) 28. Expenses Incurred on Committee Credit Card (Section P) 29. Expenses Incurred by Committee During this Period but Not Paid (Section Q) 22. In-Kind Donations not Considered Contributions Received (Section J3) 29a. Total Outstanding Expenses Incurred by Committee still Unpaid (Section Q) 17. Total Proceeds from Small Purchases at Tag Sales, Auctions or Other Sales (Section J1) COLUMN A COLUMN B This Period Aggregate Page 2 of 16 26. Beginning Loan Balance 25. Receipts of Organization Expenditures (Section M) OPTIONAL $ Method of Contribution: Cash Personal Check Money Order Credit/Debit Card Is this contribution associated with a Yes fundraising event listed in Section J1? No If yes, list Event #: I. MONETARY RECEIPTS (Sections A I) Page 3 of 16 $ A. Total Contributions from Small Contributors-Received this Period ONLY TYPE OF REPORT For Nonparticipating Candidates ONLY NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 Residential Street Address City State Zip Code Name of Employer MI First Last Name Principal Occupation Is contributor a lobbyist, spouse, Yes or dependent child of a lobbyist? No Is contributor a principal of a state contractor or prospective state contractor? Yes No If yes, indicate which branch or branches of government the contract is with: Executive Legislative Date Received Aggregate Contributions Amount of Contribution B. Itemized Contributions from Individuals TOTAL of additional Section B Pages SUBTOTAL Section B This Page Residential Street Address City State Zip Code Name of Employer MI First Last Name Principal Occupation Is contributor a lobbyist, spouse, Yes or dependent child of a lobbyist? No Is contributor a principal of a state contractor or prospective state contractor? Yes No If yes, indicate which branch or branches of government the contract is with: Executive Legislative Aggregate Contributions Amount of Contribution Contribution ID # Contribution ID # Is this contribution associated with a Yes fundraising event listed in Section J1? No If yes, list Event #: Method of Contribution: Cash Personal Check Money Order Credit/Debit Card Date Received Residential Street Address City State Zip Code Name of Employer MI First Last Name Principal Occupation Is contributor a lobbyist, spouse, Yes or dependent child of a lobbyist? No Is contributor a principal of a state contractor or prospective state contractor? Yes No If yes, indicate which branch or branches of government the contract is with: Executive Legislative Aggregate Contributions Amount of Contribution Contribution ID # Is this contribution associated with a Yes fundraising event listed in Section J1? No If yes, list Event #: Method of Contribution: Cash Personal Check Money Order Credit/Debit Card Date Received TOTAL OF ALL CONTRIBUTIONS FROM INDIVIDUALS (Sections A + B) (Enter total on Line 14 of Summary Page Totals) C2. Reimbursements, Payments, or Surplus Distributions from other Committees NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) TYPE OF REPORT C1. Contributions from Other Committees Address City Name of Committee State Zip Code Date Received Amount of Receipt Name of Treasurer Reimbursement for shared expense Payment for goods and services Yes No Is this contribution associated with a fundraising event listed in Section J1? If yes, list Event # Aggregate Contributions Date Received Amount of Contribution Name of Treasurer Address City State Zip Code Name of Committee TOTAL OF ALL COMMITTEE CONTRIBUTIONS AND RECEIPTS (Sections C1 + C2) (Enter total on Line 15 of Summary Page Totals) TOTAL of additional Section C Pages SUBTOTAL Section C This Page Address City Name of Committee State Zip Code Date Received Amount of Receipt Name of Treasurer Aggregate Contributions Date Received Amount of Contribution Name of Treasurer Address City State Zip Code Name of Committee Aggregate Contributions Date Received Amount of Contribution Name of Treasurer Address City State Zip Code Name of Committee Aggregate Contributions Date Received Amount of Contribution Name of Treasurer Address City State Zip Code Name of Committee Yes No Is this contribution associated with a fundraising event listed in Section J1? If yes, list Event # Is this contribution associated with a fundraising event listed in Section J1? If yes, list Event # Yes No Yes No Is this contribution associated with a fundraising event listed in Section J1? If yes, list Event # I. MONETARY RECEIPTS (Sections A I) Page 4 of 16 SEEC FORM 30 Rev. 1/12 Reimbursement for shared expense Payment for goods and services I. MONETARY RECEIPTS (Sections A I) Page 5 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 F. Anonymous Contributions Is there a Cosigner or Guarantor of this loan? Yes No Street Address City State Zip Code Date of Receipt Name of Lender Source of Loan: Amount Received D. Loans Received this Period Street Address City State Zip Code Name of Cosigner/Guarantor (if applicable) Is there a Cosigner or Guarantor of this loan? Yes No Street Address City State Zip Code Date of Receipt Name of Lender Source of Loan: Amount Received Street Address City State Zip Code Name of Cosigner/Guarantor (if applicable) Bank Candidate Individual Other Bank Candidate Individual Other TOTAL SECTION D Cash Personal Check Credit/Debit Card E. Personal Funds of the Candidate Received this Period (Candidate Committees ONLY) TOTAL SECTION E Date of Receipt Date of Receipt Date of Receipt Method of Payment: Method of Payment: Cash Personal Check Credit/Debit Card Cash Personal Check Credit/Debit Card Method of Payment: Amount Amount Amount Per Public Act 11-48, Anonymous Contributions may no longer be deposited in any amount. If a committee receives an anonymous contribution, the campaign treasurer shall immediately remit the contribution to the State Elections Enforcement Commission for deposit in the General Fund. G. Interest from Deposits in Authorized Accounts Street Address City State Zip Code Date Received Amount Name of Institution Street Address City State Zip Code Date Received Amount Name of Institution TOTAL SECTION G TOTAL SECTION I SUMMARY OF OTHER MONETARY RECEIPTS (Sections D through I) Total Loans Received this Period (Section D) +Total Amount of Personal Funds of the Candidate Received this Period (Section E) + Total Amount of Interest from Deposits in Authorized Accounts (Section G) + Total Public Grant Funds Received from the Citizens Election Fund (Section H) +Total Miscellaneous Monetary Receipts not Considered Contributions (Section I) + TOTAL OF OTHER MONETARY RECEIPTS NOT CONSIDERED CONTRIBUTIONS (Add Sections D through I) (Enter total on Line 16 of Summary Page Totals) H. Public Grant Funds Received from the Citizens Election Fund I. Miscellaneous Monetary Receipts not Considered Contributions TOTAL SECTION H Street Address Name Amount Received Date of Transaction City State Zip Code Description Amount Date Received Purpose of Grant: Primary General Election Special Election Grant Cycle: Initial Grant Adjustment Supplemental/Post Election Deficit I. MONETARY RECEIPTS (Sections A I) Page 6 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 Primary General Election Special Election Amount Date Received Purpose of Grant Grant Cycle: Initial Grant Adjustment Supplemental/Post Election Deficit Primary General Election Special Election Amount Date Received Purpose of Grant: Grant Cycle: Initial Grant Adjustment Supplemental/Post Election Deficit Primary General Election Special Election Amount Date Received Purpose of Grant: Grant Cycle: Initial Grant Adjustment Supplemental/Post Election Deficit Street Address Name Amount Received Date of Transaction City State Zip Code Description Street Address Name Amount Received Date of Transaction City State Zip Code Description J1. Fundraising Event Information Was this fundraising event hosted at a personal residence? Yes If yes, go to Section J3 In-Kind Donations not Considered Contributions and complete required information for purchases made by host(s) for food, beverage and invitations. No Did this fundraiser include items donated by a business entity of up to Yes If yes, go to Section J3 In-Kind Donations not Considered Contributions $100 or items donated by an individual of up to $100? and complete required information. No Was this fundraiser a tag sale, auction, or other sale of donated items Yes (If yes, enter Total Receipts here.) with purchases from an individual of up to $100? No Date of Fundraiser Description City State Zip Code Letter Fundraising Event # II. FUNDRAISING EVENT ACTIVITY (Sections J1 J3) Page 7 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 Was this fundraising event hosted at a personal residence? Yes If yes, go to Section J3 In-Kind Donations not Considered Contributions and complete required information for purchases made by host(s) for food, beverage and invitations. No Did this fundraiser include items donated by a business entity of up to Yes If yes, go to Section J3 In-Kind Donations not Considered Contributions $100 or items donated by an individual of up to $100? and complete required information. No Description City State Zip Code Was this fundraising event hosted at a personal residence? Yes If yes, go to Section J3 In-Kind Donations not Considered Contributions and complete required information for purchases made by host(s) for food, beverage and invitations. No Did this fundraiser include items donated by a business entity of up to Yes If yes, go to Section J3 In-Kind Donations not Considered Contributions $100 or items donated by an individual of up to $100? and complete required information. No Description City State Zip Code $ Location: Street Address TOTAL of additional Section J1 Pages SUBTOTAL Section J1 Subpart 1 Total Receipts from Sale of Donated Items This Page TOTAL OF ALL SMALL PURCHASES FROM TAG SALES, AUCTIONS OR OTHER SALE OF DONATED ITEMS (Enter total on Line 17 of Summary Page Totals) Subpart 1: Date of Fundraiser Letter Fundraising Event # Date of Fundraiser Letter Fundraising Event # $ Subpart 1: Was this fundraiser a tag sale, auction, or other sale of donated items Yes (If yes, enter Total Receipts here.) with purchases from an individual of up to $100? No Location: Street Address Location: Street Address $ Subpart 1: Was this fundraiser a tag sale, auction, or other sale of donated items Yes (If yes, enter Total Receipts here.) with purchases from an individual of up to $100? No J3. In-Kind Donations Not Considered Contributions II. FUNDRAISING EVENT ACTIVITY (Sections J1 J3) Page 8 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 Per Public Act 11-48, effective January 1, 2012 committees are no longer required to itemize small individual purchases from a committee tag sale, auction, or a sale of donated items. Section J2. removed SUBTOTAL Section J3 This Page TOTAL of additional Section J3 Pages TOTAL OF ALL IN-KIND DONATIONS NOT CONSIDERED CONTRIBUTIONS (Enter total on Line 22 of Summary Page Totals) Description of Donation Date Received Event # Street Address City State Zip Code Name of Donor Aggregate Value for this Event Fair Market Value of Donation Donation Given By: Individual Business Entity Sole Proprietorship Description of Donation Date Received Event # Street Address City State Zip Code Name of Donor Aggregate Value for this Event Fair Market Value of Donation Donation Given By: Individual Business Entity Sole Proprietorship Description of Donation Date Received Event # Street Address City State Zip Code Name of Donor Aggregate Value for this Event Fair Market Value of Donation Donation Given By: Individual Business Entity Sole Proprietorship Description of Donation Date Received Event # Street Address City State Zip Code Name of Donor Aggregate Value for this Event Fair Market Value of Donation Donation Given By: Individual Business Entity Sole Proprietorship Is this contribution associated with a Yes fundraising event listed in Section L1? No If yes, list Event #: MI Amount of Deposit NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) TYPE OF REPORT K. In-Kind Contributions Last Name of Individual Residential Street Address City State Zip Code Date Deposit Made Name of Telephone Company Street Address City TOTAL SECTION L (Enter total on Line 24 of Summary Page Totals) First SUBTOTAL Section K This Page TOTAL of additional Section K Pages TOTAL OF ALL IN-KIND CONTRIBUTIONS (Enter total on Line 23 of Summary Page Totals) State Zip Code Description of In-Kind Contribution Street Address City State Zip Code Is contributor a lobbyist, spouse, Yes or dependent child of a lobbyist? No Name Fair Market Value of this Contribution L. Refundable Deposit to Telephone Company III. NONMONETARY RECEIPTS (Sections K M) Page 9 of 16 SEEC FORM 30 Rev. 1/12 Is contributor a principal of a state contractor or prospective state contractor? Yes If yes, indicate which branch or branches No of government the contract is with: Executive Legislative Date Received Aggregate Contributions Description of In-Kind Contribution Street Address City State Zip Code Is contributor a lobbyist, spouse, Yes or dependent child of a lobbyist? No Name Fair Market Value of this Contribution Is this contribution associated with a Yes fundraising event listed in Section L1? No If yes, list Event #: Description of In-Kind Contribution Street Address City State Zip Code Is contributor a lobbyist, spouse, Yes or dependent child of a lobbyist? No Name Fair Market Value of this Contribution Is this contribution associated with a Yes fundraising event listed in Section L1? No If yes, list Event #: Is contributor a principal of a state contractor or prospective state contractor? Yes If yes, indicate which branch or branches No of government the contract is with: Executive Legislative Date Received Aggregate Contributions Is contributor a principal of a state contractor or prospective state contractor? Yes If yes, indicate which branch or branches No of government the contract is with: Executive Legislative Aggregate Contributions Date Received Type of Contributor: Individual Committee Sole Proprietorship Type of Contributor: Individual Committee Sole Proprietorship Type of Contributor: Individual Committee Sole Proprietorship Fair Market Value of Donation NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) TYPE OF REPORT M. Non-Monetary Receipts of Organization Expenditures Made By Legislative Leadership, Legislative Caucus and Party Committees OPTIONAL See Public Act 11-48 Date Notice Received Aggregate Donations Name of Treasurer Street Address City State Zip Code Name of Committee (Legislative Leadership, Legislative Caucus, and Party Committees ONLY) Description of Donation Purpose of Expenditure (see instructions) A B C D E Date Notice Received Aggregate Donations Name of Treasurer Street Address City State Zip Code Name of Committee (Legislative Leadership, Legislative Caucus, and Party Committees ONLY) Description of Donation Purpose of Expenditure (see instructions) A B C D E Date Notice Received Aggregate Donations Name of Treasurer Street Address City State Zip Code Name of Committee (Legislative Leadership, Legislative Caucus, and Party Committees ONLY) Description of Donation Purpose of Expenditure (see instructions) A B C D E Date Notice Received Aggregate Donations Name of Treasurer Street Address City State Zip Code Name of Committee (Legislative Leadership, Legislative Caucus, and Party Committees ONLY) Description of Donation Purpose of Expenditure (see instructions) A B C D E Date Notice Received Aggregate Donations Name of Treasurer Street Address City State Zip Code Name of Committee (Legislative Leadership, Legislative Caucus, and Party Committees ONLY) Description of Donation Purpose of Expenditure (see instructions) A B C D E Fair Market Value of Donation Fair Market Value of Donation Fair Market Value of Donation Fair Market Value of Donation SUBTOTAL Section M This Page TOTAL of additional Section M Pages TOTAL RECEIPTS OF ALL ORGANIZATION EXPENDITURES (Enter total on Line 25 of Summary Page Totals) III. NONMONETARY RECEIPTS (Sections K M) Page 10 of 16 SEEC FORM 30 Rev. 1/12 IV. EXPENDITURES (Sections N S) Page 11 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 N. Expenses Paid by Committee Method of Payment: Amount Date of Payment Check #________ Debit Card Description Purpose of Expenditure (by code) Name of Payee Street Address City State Zip Code Event # Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum N Expenditure # (if applicable) Method of Payment: Amount Date of Payment Check #________ Debit Card Description Purpose of Expenditure (by code) Name of Payee Street Address City State Zip Code Event # Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum N Expenditure # (if applicable) Method of Payment: Amount Date of Payment Check #________ Debit Card Description Purpose of Expenditure (by code) Name of Payee Street Address City State Zip Code Event # Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum N Expenditure # (if applicable) Method of Payment: Amount Date of Payment Check #________ Debit Card Description Purpose of Expenditure (by code) Name of Payee Street Address City State Zip Code Event # Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum N Expenditure # (if applicable) SUBTOTAL Section N This Page TOTAL of additional Section N Pages TOTAL OF ALL EXPENSES PAID BY COMMITTEE (Enter total on Line 20 of Summary Page Totals) Is reimbursement claimed? IV. EXPENDITURES (Sections N S) Page 12 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 Amount Date of Payment Description Purpose of Expenditure (by code) Name of Payee (Name of vendor who candidate paid directly) Street Address City State Zip Code Event # O. Expenses Paid by Candidate Yes No Is reimbursement claimed? Amount Date of Payment Description Purpose of Expenditure (by code) Name of Payee (Name of vendor who candidate paid directly) Street Address City State Zip Code Event # Yes No Is reimbursement claimed? Amount Date of Payment Description Purpose of Expenditure (by code) Name of Payee (Name of vendor who candidate paid directly) Street Address City State Zip Code Event # Yes No Is reimbursement claimed? Amount Date of Payment Description Purpose of Expenditure (by code) Name of Payee (Name of vendor who candidate paid directly) Street Address City State Zip Code Event # Yes No Is reimbursement claimed? Amount Date of Payment Description Purpose of Expenditure (by code) Name of Payee (Name of vendor who candidate paid directly) Street Address City State Zip Code Event # Yes No Is reimbursement claimed? Amount Date of Payment Description Purpose of Expenditure (by code) Name of Payee (Name of vendor who candidate paid directly) Street Address City State Zip Code Event # Yes No SUBTOTAL Section O This Page TOTAL of additional Section O Pages TOTAL OF ALL EXPENSES PAID BY CANDIDATE (Enter total on Line 27 of Summary Page Totals) IV. EXPENDITURES (Sections N S) Page 13 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 P. Expenses Incurred on Committee Credit Card Name of Issuing Institution Type of Credit Card: Visa Master Card Discover American Express Other SUBTOTAL Section P This Page TOTAL of additional Section P Pages TOTAL OF ALL EXPENSES INCURRED ON COMMITTEE CREDIT CARD (Enter total on Line 28 of Summary Page Totals) Amount Date of Transaction Description Purpose of Expenditure (by code) Name of Vendor Street Address City State Zip Code Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum P Amount Date of Transaction Description Purpose of Expenditure (by code) Name of Vendor Street Address City State Zip Code Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum P Amount Date of Transaction Description Purpose of Expenditure (by code) Name of Vendor Street Address City State Zip Code Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum P Amount Date of Transaction Description Purpose of Expenditure (by code) Name of Vendor Street Address City State Zip Code Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum P IV. EXPENDITURES (Sections N S) Page 14 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 Q. Expenses Incurred by Committee but Not Paid During this Period SUBTOTAL Section Q This Page TOTAL of additional Section Q Pages TOTAL OF ALL EXPENSES INCURRED BY COMMITTEE DURING THIS PERIOD BUT NOT PAID (Enter total on Line 29 of Summary Page Totals) Previously reported Expenses Unpaid and still Outstanding TOTAL OF ALL EXPENSES INCURRED BY COMMITTEE BUT NOT PAID (Enter total on Line 29a of Summary Page Totals) Amount Incurred (Estimate or Actual) Date Incurred Description Purpose of Expenditure (by code) Name of Creditor Street Address City State Zip Code Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum Q Amount Incurred (Estimate or Actual) Date Incurred Description Purpose of Expenditure (by code) Name of Creditor Street Address City State Zip Code Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum Q Amount Incurred (Estimate or Actual) Date Incurred Description Purpose of Expenditure (by code) Name of Creditor Street Address City State Zip Code Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum Q Amount Incurred (Estimate or Actual) Date Incurred Description Purpose of Expenditure (by code) Name of Creditor Street Address City State Zip Code Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum Q IV. EXPENDITURES (Sections N S) Page 15 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 R. Itemization of Reimbursements to Committee Workers and Consultants Method of Payment: Amount Date of Payment Check #________ Debit Card Description Purpose of Expenditure (by code) Street Address City State Zip Code Last Name of Worker/Consultant First MI Secondary Payee Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum R SUBTOTAL Section R This Page TOTAL of additional Section R Pages TOTAL OF ALL REIMBURSEMENTS TO COMMITTEE WORKERS AND CONSULTANTS Method of Payment: Amount Date of Payment Check #________ Debit Card Description Purpose of Expenditure (by code) Street Address City State Zip Code Last Name of Worker/Consultant First MI Secondary Payee Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum R Method of Payment: Amount Date of Payment Check #________ Debit Card Description Purpose of Expenditure (by code) Street Address City State Zip Code Last Name of Worker/Consultant First MI Secondary Payee Event # Expenditure # (if applicable) Is this expenditure coordinated with another candidate for which Yes reimbursement is sought? No If yes, assign an Expenditure # and complete Itemization in Addendum R IV. EXPENDITURES (Sections N S) Page 16 of 16 TYPE OF REPORT NAME OF COMMITTEE (Provide Complete Name as Registered with Commission) SEEC FORM 30 Rev. 1/12 S. Surplus Distribution of Equipment and Furniture TOTAL SECTION S Street Address City State Zip Code Description of Item Original Purchase Amount of Item Name of Recipient Street Address City State Zip Code Description of Item Original Purchase Amount of Item Name of Recipient Street Address City State Zip Code Description of Item Original Purchase Amount of Item Name of Recipient Street Address City State Zip Code Description of Item Original Purchase Amount of Item Name of Recipient Street Address City State Zip Code Description of Item Original Purchase Amount of Item Name of Recipient Street Address City State Zip Code Description of Item Original Purchase Amount of Item Name of Recipient Warning: The existence of a particular expenditure code does not mean that such expenditure is lawful. To determine lawfulness, Treasurers must read the committee guide applicable to their type of committee or contact the State Elections Enforcement Commission at 860-256-2925. Advertising: Each expenditure code beginning with "A-" is to be used to identify the delivery method for paid advertising, which includes advertising to solicit committee funds. Include the costs for both the development and the delivery of the message. A payment to a professional consultant to develop a message should be coded to the main advertising delivery method below, not as Professional Consultant (CNSLT), which is a code that should only be used when no other expenditure code applies. If a single advertising message is developed for several of the delivery mechanisms listed below, use A-OTH for the cost of developing the message and then use the applicable code for the payments associated with the several delivery methods used. Please Note: The one exception to this advertising rule is when advertising content includes, as part of the message, an invitation to individuals to attend a fundraising event in return for a contribution or attendance fee. Fundraising Event advertising must be coded FNDR (see explanation below) irrespective of the advertising delivery method. A-DM: expenditure to advertise through direct mail. A-MAG: expenditure to advertise through a magazine. A-NEWS: expenditure to advertise through a newspaper. A-ATM: expenditure to advertise using an automated telephone/fax message, or an automated telemarketing message. A-PH-BNK: expenditure for the use of phone banks, where people are speaking as distinguished from pre-recorded messages (above) and polls and surveys (below). A-RAD: expenditure to advertise on radio. A-SIGN: expenditure for the cost of preparing, printing, producing or distributing lawn or billboard signs visible from any street or highway. A-TV: expenditure to advertise on television. A-WEB: expenditure to advertise on the World Wide Web. This includes webcasting (sending audio and/or video live over the Internet), or any other form of advertising on the web. See WEB for other web-related expenditures. A-OTH: expenditure for any other advertising, not listed above, like the cost of (a) posters, stickers, streamers, banners, etc. for distribution on or in buildings or vehicles ( cars, buses, boats, aircraft, etc.); (b) campaign paraphernalia, such as pins, hats, potholders, tee shirts and other campaign giveaway items; (c) audio messages and the cost of transmitting them by speakers from vehicles or buildings; (d) ads placed in ad books, in schools or civic organizations ad book pamphlets or bulletins; or (e) ads placed in ad books for fundraising events held by other committees. *ATT: expenditure for attendance fee or entrance fee for any person to a (1) fundraiser held by any committee; (2) an inaugural event of any candidate; (3) a charitable event; (4) an educational course or training seminar; etc. In the text box of the Description Field, which is mandatory under this expenditure category, identify the name and address of the individual who is attending the event as well as the date and location of the event and the name of the sponsoring committee or entity sponsoring the event. BNK: expenditure to record any payment of BANK fees, interest charges, or penalties assessed by the bank on the committee s checking account only. Similar fees assessed by a credit card company should be listed under credit card charges in Section P of the SEEC Form 30, entitled Expenses Incurred on Committee Credit Card. CCP: expenditure to record any payment of the Credit Card bill, including partial payments, finance charges, and mid-cycle payments. See Section P of the SEEC Form 30, entitled Expenses Incurred on Committee Credit Card, to record actual charges made against the credit card account, including any finance charges. CEF: expenditure to record any payment to the State of Connecticut s Citizens Election Fund (CEF). Checks should be made payable to the Citizens Election Fund and sent to the State Elections Enforcement Commission, 20 Trinity Street, Hartford, CT 06106. This expenditure code does not apply to the surplus distribution (SRPLS) expenditure code explained below. CHAR: expenditure for a payment of committee funds to a tax-exempt charitable organization [26 Code 501(c)(3)]. EXPENDITURE CODE ADDENDUM For use with Sections N, O, P, Q & R of the SEEC Form 30 Asterisk * adjacent to the left of the Expenditure Code indicates that Description Field is Mandatory CNSLT: expenditures to a professional consultant. Professional consultants are individuals or entities that are paid by the committee as independent contractors for their professional advice. They are not salaried employees and they are not individuals who are serving the committee as volunteers. Examples: management firms, public relations firms, lawyers and accountants, etc. However, for payments to professional consultants who design polls and surveys, or advertising messages, use the more specific code (ex. A-DM, A-OTHR, POLLS). If the payment to a professional consultant includes costs paid or incurred to some other vendor, following completion of the entry of this expenditure, go immediately to Section R, Itemization of Reimbursements to Committee Workers and Consultants, and follow the instructions for reporting of Secondary Payees. CNTRB: expenditures that are contributions to another committee. The expenditure of a committee s funds to make a contribution to another committee is to be distinguished from an expenditure of committee funds to pay the other committee (POC) for shared expenses. See explanation of POC below. *EFV: expenditures for equipment, furniture, and vehicles. Record only the portion of the cost that is actually paid. Cost includes any costs associated with the delivery or installation of the item. Equipment includes computers, printers, phones, etc. The text box of the Description Field, which is mandatory in this situation, must list the item, and whether the expenditure is a purchase, rental or lease. Please Note: Vehicles may only be leased and may not be purchased. FOOD: expenditures paid directly to a vendor for food and beverage, except if the vendor is paid for these items in association with the committee s own sponsored fundraiser (see FNDR below) or the committee s own sponsored inaugural event (see INAUG below). *FNDR: expenditures associated with holding a committee fundraising event ( payments to restaurants, hotels, caterers, food and beverage vendors, invitations, entertainers performing at the event, paid speakers, etc.). Advertising content that includes as part of the message invitations to individuals to attend a committee fundraising event in return for a contribution or attendance fee must be coded FNDR irrespective of the advertising delivery method. Please Note: This expenditure category must not include expenditures of the committee s funds for the attendance fees (ATT) of any persons attending another entity s fundraising event. *GIFT: record the purchase of any item that is to be given as a gift to any individual or entity. Gifts to committee workers are generally limited to an aggregate of $100 per recipient. For committees that have received a CEP grant, the limit is $5 per recipient. The text box of the Description Field, which is mandatory in this situation, must identify the item purchased as well as the name and address of the individual or entity who is the recipient of the committee s gift. INAUG: expenditures relating to the committee s costs for hosting an inaugural event for the committee s own candidate. This code does not include expenditures by the committee for attendance fees of individuals to another committee s inaugural event, which must be coded as an attendance fee (see ATT above). LOAN: expenditures to record the payment of the committee's LOAN, whether principal, interest or both. Please Note: Any penalties assessed for non-payment on a loan, if not paid by the payment due date, must be disclosed as additional Expenses Incurred by Committee but not Paid During This Period in Section Q of the SEEC Form 30. OFFICE: expenditures for office supplies such as paper, pens, printer cartridges, etc. OVHD: expenditures of overhead operating costs, including the cost of renting office space, parking spaces, repairing or servicing office furniture and equipment used in connection with committee activities, related insurance, utility payments for committee headquarters, subscriptions and similar overhead operating expenses. PETTY: expenditure to replenish the committee s petty cash fund. POC: expenditures to record a payment to another committee at fair market value for goods, services or other things of value provided by that other committee as a reimbursement of a shared expense. Examples: payment for a mail list, contact list or email distribution list prepared and produced by the other committee, or for the cost of the salaries of the other committee s salaried employees who were loaned to the committee, etc. Absent payment to the other committee at fair market value for such benefits received, within 45 days of receipt, the committee would be receiving an In-Kind Contribution from the other committee. Please Note: In-Kind Contributions do not require an expenditure code because they are receipts of the committee, not expenditures. The POC expenditure code category must be distinguished from expenditures that are coded as contributions to another committee (CNTRB). EXPENDITURE CODE ADDENDUM For use with Sections N, O, P, Q & R of the SEEC Form 30 Asterisk * adjacent to the left of the Expenditure Code indicates that Description Field is Mandatory If additional pages are needed to complete all information required in each section of the form, please reproduce the Additional Page for the appropriate section, and attach the page(s) to the section. Additional Pages are located at the back of the SEEC Form 30. POLLS: expenditures associated with conducting polls and surveys. This category is to be distinguished from phone banks (A-PH-BNK) because the information is not just delivered to the public but opinion is carefully being sought and collected from the public in some manner to produce a poll or survey result or report. If a professional consultant is both designing and conducting the poll or survey, use POLLS as the expenditure code, not CNSLT (see above). POST: expenditures for postage, such as stamps, bulk mail permits, post office boxes and envelopes, United Parcel Service, Federal Express, etc. PRNT: expenditures associated with the costs of printing, photocopying or reproducing literature, stationery, invitations and the like. RCW: expenditures to reimburse committee workers, which may include a candidate. This is when the cost of payment for something needed by the committee is advanced by the committee worker and reimbursement is sought and obtained from the committee s Treasurer who authorized the payment within 45 days of receipt of the paid for item. Please Note: Absent reimbursement to the committee worker within 45 days of receipt of the paid for item, the committee would be receiving an In Kind Contribution from the committee worker. After making payment to the worker, reporting this item also requires full reporting of the Secondary Payees appearing on the payment slip of the committee worker. Go immediately to Section R, Itemization of Reimbursements to Committee Workers and Consultants, and follow the instructions for reporting of Secondary Payees. Further Note: When reimbursing the candidate, report the purchase in Section O of the SEEC Form 30, entitled Campaign Expenses Paid by the Candidate. REF: refunds are expenditures of any committee funds that were deposited into the committee s checking account and then returned to a contributor or any other revenue source for any reason. SRPLS: expenditures which are surplus distributions in connection with the termination and dissolution of the committee. TRVL: expenditures for an individual s transportation costs and lodging authorized by the Treasurer, such as the cost of gasoline, other transportation fare, and lodging. The cost of attending any event should be coded as attendance (see ATT above) and any separate payment for food outside the cost of the attendance fee should be coded as FOOD. WAGE: expenditures for wages and benefits paid to the committee s staff. This is to be distinguished from payments to professional consultants (CNSLT) who are independent contractors. WEB: expenditures for accessing and having a presence on the WEB. This includes payments to develop or maintain: (a) a committee website and homepage; (b) an internet provider; (c) a domain name on the internet; (d) payments to a merchant account processor or a payment gateway provider to enable the committee to receive online credit and debit card contributions over the internet; and (e) similar costs relating to use of the internet. This is not to be used for any costs related to advertising on the web (see A-WEB above). *MISC: expenditures of Miscellaneous items that are not listed above. The text box of the Description Field, which is mandatory in this situation, must explain in narrative form, with sufficient clarity, the purpose of this expenditure. EXPENDITURE CODE ADDENDUM For use with Sections N, O, P, Q & R of the SEEC Form 30 Asterisk * adjacent to the left of the Expenditure Code indicates that Description Field is Mandatory If additional pages are needed to complete all information required in each section of the form, please reproduce the Additional Page for the appropriate section, and attach the page(s) to the section. Additional Pages are located at the back of the SEEC Form 30.

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