Fillable Page 1 of 10 CFC-CCDR-FR&TS 1/14 (Walton County Board of Commissioners)

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Page 1 of 10 CFC-CCDR-FR&TS 1/14 (Walton County Board of Commissioners)

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BROWSE WALTON COUNTY BOARD OF COMMISSIONERS (GA) FORMS

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Page 1 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
CFC-CCDR-FR&TS 1/14
Campaign Contribution Disclosure Final Report and Termination Statement
Georgia Government Transparency and Campaign Finance Commission
200 Piedmont Avenue SE, Suite 1402 West Tower | Atlanta, GA 30334 | 404-463-1980 |
www.ethics.ga.gov
1. Report Type
(Select One)
Original
Amendment
Amendment # ____________
2. Filing is being made on behalf of (Select One):
Candidate or Public Official
Office Held or Sought ______________________________________________
(Include county, municipality, district, post or judicial circuit)
Filer ID ___________________________________________________
(Filer ID that begins with the letter “C”)
Organization or Person Other than Candidate’s Campaign Committee
Committee Name: ______________________________________________
Filer ID: ______________________________________________
(Filer ID that begins with the letter “NC”)
Use Earlier of Post
Mark or Hand
Delivered Date
3. Identifying and Contact Information
(1)______________________________________________________________________
(2) _____________________
Full Name of Candidate or Other Than Candidate Campaign Committee
Today’s Date
(3) _______________________________________________________________________________________________
Mailing Address City State Zip Code
(4) __________________________________________________
and/ or _____________________________________
Primary Contact Phone Number
E-Mail
(5) If a Candidate or Public Official is there a campaign committee (one or more persons) to make campaign transactions, keep
financial records of the campaign, or file the reports?
Yes No
(6) If yes, is the committee registered with the Commission?
Yes No
(7) If yes, complete the following______________________________________________________________________
Name of Committee Chairperson Name of Committee Treasurer
4. Person Responsible for Maintaining Campaign Records
__________________________________________________________________________________________________________
(1) Full Name
__________________________________________________________________________________________________________
(2) Mailing Address
______________________________________________________________________________________
(3) City
(4)____________________________________________
(5)
Primary Contact Phone Number Email Address
5. TERMINATION DATE: ___________________________________________
State of County of
I, , being duly sworn (affirm), depose and say that the information in this report form is
complete, true, and correct. Further, I affirm that the contents in this report are the same as the contents in the electronic filing submitted, if
also electronically filed.
Sworn to and subscribed before me on , 20
___________________________________ __________________________________ _______________________________________
Signature of Notary Public
Commission Expiration
a. Signature of Candidate
b. Organization/Chairperson/Treasurer
(Any person who knowingly fails to comply with or who knowingly violates any of the provisions of the Act shall be guilty of a misdemeanor.)
Zip Code
State
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Page 2 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
State of Georgia
Campaign Contribution Disclosure Report
Summary Report
CONTRIBUTIONS RECEIVED
1
I have no contributions to report.
I have the following contributions, including Common Source, to report:
In-Kind
Estimated Value
2
A. If this is the first time to file a disclosure report for the current office sought,
ENTER 0 in both columns (one time only); or
B. If this is the first report of this Election Cycle*, ENTER 0 in the in-kind
column and list any net balance on hand brought forward from the previous
election cycle in the cash amount column (Line 15 of previous report, or total
funds left over at year end of previous cycle); or
C. If this filing is the second or subsequent filing of this Election Cycle, list totals
from Line 6 of previous report in both the in-kind and cash amount columns.
3
Total amount of all itemized contributions received in this reporting period which
is listed on the "Itemized Contributions" page.
3a
All loans received this reporting period.
3b
Interest earned on campaign account this reporting period.
3c
Total amount of investments sold this reporting period.
3d
Total amount of cash dividends and interest paid out this reporting period.
4
Total amount of all separate contributions of $100 or less received in this
reporting period and not listed on the "Itemized Contributions" page.
"Common Source" contributions must be aggregated on the "Itemized
Contributions" page.
5
Total contributions reported this period.
(Line 3 + 3a + 3b + 3c + 3d + 4)
6
Total contributions to date. Total to be carried forward to next report of this
election cycle*.
(Line 2 + 5)
EXPENDITURES MADE
7
I have no expenditures to report.
I have the following expenditures to report:
8
Total expenditures made and reported prior to this reporting period. If this is the
A. First report of this Election Cycle*, ENTER 0.
B. Second or subsequent filing ENTER Line 12 of previous report.
9
Total amount of all itemized expenditures made in this reporting period which are
listed on the "Itemized Expenditures" page.
10
Total amount of all separate expenditures of $100.00 or less that were made
in this reporting period and not listed on the "Itemized Expenditures" page
11
Total expenditures reported this period.
(Line 9 + 10)
12
Total expenditures to date. Total to be carried forward to next report of this
election cycle*.
(Line 8 + 11)
INVESTMENTS
13
Total value of investments held at the beginning of this reporting period.
14
Total value of investments held at the end of this reporting period.
TOTAL NET BALANCE ON HAND
15
Net balance on hand.
(Line 6 - 12 + 14)
* O.C.G.A. 21-5-3(10) : Election cycle means the period from the day following the date of an election or appointment of a person to elective public office through and
of the next such election of a person to the same public office and shall be construed and applied separately for each elective office including the date.
CFC-CCDR-FR&TS 1/14
Page 3 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
State of Georgia
Campaign Contribution Disclosure Report
Outstanding Indebtness
Election Cycle*: ______________________ Election Year: ____________
Amount
1
Outstanding indebtedness at the beginning of this reporting period.
2
Loans received this reporting period.
3
Deferred payment of expenses this reporting period
4
Payments made on loans this reporting period.
5
Credits received on loans this reporting period
6
Payments this reporting period on previously deferred expenses.
7
Total indebtedness at the close of this reporting period. (Line 1 + 2 + 3 - 4 - 5 - 6)
Election Cycle*: ______________________ Election Year: ____________
Amount
1
Outstanding indebtedness at the beginning of this reporting period.
2
Loans received this reporting period.
3
Deferred payment of expenses this reporting period
4
Payments made on loans this reporting period.
5
Credits received on loans this reporting period
6
Payments this reporting period on previously deferred expenses.
7
Total indebtedness at the close of this reporting period. (Line 1 + 2 + 3 - 4 - 5 - 6)
Election Cycle*: ______________________ Election Year: ____________
Amount
1
Outstanding indebtedness at the beginning of this reporting period.
2
Loans received this reporting period.
3
Deferred payment of expenses this reporting period
4
Payments made on loans this reporting period.
5
Credits received on loans this reporting period
6
Payments this reporting period on previously deferred expenses.
7
Total indebtedness at the close of this reporting period. (Line 1 + 2 + 3 - 4 - 5 - 6)
* Election Cycle (Primary, General, Special, Special Primary, Run-Off Primary, Run-Off General, Run-Off Special, Run-Off Special Primary)
Public Officer/Candidate/Other Than Candidate Committee Name
CFC-CCDR-FR&TS 1/14
Page 4 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
State of Georgia
Campaign Contribution Disclosure Report
Itemized Contributions
Must list contributions received by a single contributor for which the aggregate total more than $100.00.
Note: Loans are no longer reported in “Itemized Contributions” section. See Loan Reporting section below.
Full Name of Contributor
Mailing Address
(Affiliation of Committee if any)
Contributor
Election
Cycle**
Cash
Amount
In-Kind
Contributions
Received Date
Contribution Type*
Occupation &
Employer
Estimated Value
Description
First Name / Business Name
Date
Occupation
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Cash Amt.
Est. Value
Last Name
Address
Address2
Monetary
In-Kind
Common Source
Credit Received on Loan
Employer
Description
City
State
Zip
Aff. Comm.
First Name / Business Name
Date
Occupation
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Cash Amt.
Est. Value
Last Name
Address
Address2
Monetary
In-Kind
Common Source
Credit Received on Loan
Employer
Description
City
State
Zip
Aff. Comm.
First Name / Business Name
Date
Occupation
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Cash Amt.
Est. Value
Last Name
Address
Address2
Monetary
In-Kind
Common Source
Credit Received on Loan
Employer
Description
City
State
Zip
Aff. Comm.
Itemized Contributions Page Total $ ____________ $______________
CFC-CCDR-FR&TS 1/14
Page 5 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
Itemized Contributions Page Total $ ____________ $______________
* Contribution Type (Monetary, In-Kind, Common Source, Credit Received on Loan)
** Election Cycle (Primary, General, Special, Special Primary, Run-Off Primary, Run-Off General, Run-Off Special, Run-Off Special Primary)
*** If any such person(s) shall have a fiduciary relationship to the lending institution or party making the advance or extension of credit
First Name / Business Name
Date
Occupation
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Cash Amt.
Est. Value
Last Name
Address
Address2
Monetary
In-Kind
Common Source
Credit Received on Loan
Employer
Description
City
State
Zip
Aff. Comm.
First Name / Business Name
Date
Occupation
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Cash Amt.
Est. Value
Last Name
Address
Address2
Monetary
In-Kind
Common Source
Credit Received on Loan
Employer
Description
City
State
Zip
Aff. Comm.
First Name / Business Name
Date
Occupation
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Cash Amt.
Est. Value
Last Name
Address
Address2
Monetary
In-Kind
Common Source
Credit Received on Loan
Employer
Description
City
State
Zip
Aff. Comm.
First Name / Business Name
Date
Occupation
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Cash Amt.
Est. Value
Last Name
Address
Address2
Monetary
In-Kind
Common Source
Credit Received on Loan
Employer
Description
City
State
Zip
Aff. Comm.
CFC-CCDR-FR&TS 1/14
Page 6 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
Loan Reporting
Name of Lender
&
Mailing Address
1.Date of Loan
2.Amount of Loan
3.Election Cycle**
Person(s) responsible for
repayment of loan &
Mailing Address
1.Occupation &
2.Place of Employment
Lender Name (First Name, Business, Inst.)
1.
First Name
1.
Lender Last Name
2.
Last Name
2.
Address
3.
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Address
Address2
Address2
City
City
State
Zip
State
Zip
Lender Name (First Name, Business, Inst.)
1.
First Name
1.
Lender Last Name
2.
Last Name
2.
Address
3.
Primary
General
Special
Special Primary
Run-Off Primary
Run-Off General
Run-Off Special
Run-Off Special
Primary
Address
Address2
Address2
City
City
State
Zip
State
Zip
Reference: OCGA § 21-5-34(b)(1) Loan Page Total $ ____________
* Contribution Type (Monetary, In-Kind, Common Source, Credit Received on Loan)
** Election Cycle (Primary, General, Special, Special Primary, Run-Off Primary, Run-Off General, Run-Off Special, Run-Off Special Primary)
CFC-CCDR-FR&TS 1/14
Page 7 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
State of Georgia
Campaign Contribution Disclosure Report
Itemized Expenditures
Must list expenditures made to a single recipient for which the aggregate total more than $100.00.
List Name and
Mailing Address of Recipient
Exp. Date
Exp. Type*
Occupation &
Employer
Expenditure
Purpose
Amount
Paid
First Name
Date
Occupation
Last Name
Address
Expenditure
In-Kind
Loan Repayment
Refund
Reimbursement
Credit Card
3rd Party
Deferred Payment
Payment on Deferred Expense
Investment
Address2
Employer
City
State
Zip
First Name
Date
Occupation
Last Name
Address
Expenditure
In-Kind
Loan Repayment
Refund
Reimbursement
Credit Card
3rd Party
Deferred Payment
Payment on Deferred Expense
Investment
Address2
Employer
City
State
Zip
First Name
Date
Occupation
Last Name
Address
Expenditure
In-Kind
Loan Repayment
Refund
Reimbursement
Credit Card
3rd Party
Deferred Payment
Payment on Deferred Expense
Investment
Address2
Employer
City
State
Zip
Page Total $ _________
* Expenditure Type (Expenditure, In-Kind, Loan Repayment, Refund, Reimbursement, Credit Card, 3rd Party, Deferred Payment on Deferred Expense, Investment)
Public Officer/Candidate/Other Than Candidate Committee Name
CFC-CCDR-FR&TS 1/14
Page 8 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
List Name and
Mailing Address of Recipient
Exp. Date
Exp. Type*
Occupation &
Employer
Expenditure
Purpose
Amount
Paid
First Name
Date
Occupation
Last Name
Address
Expenditure
In-Kind
Loan Repayment
Refund
Reimbursement
Credit Card
3rd Party
Deferred Payment
Payment on Deferred Expense
Investment
Address2
Employer
City
State
Zip
First Name
Date
Occupation
Last Name
Address
Expenditure
In-Kind
Loan Repayment
Refund
Reimbursement
Credit Card
3rd Party
Deferred Payment
Payment on Deferred Expense
Investment
Address2
Employer
City
State
Zip
First Name
Date
Occupation
Last Name
Address
Expenditure
In-Kind
Loan Repayment
Refund
Reimbursement
Credit Card
3rd Party
Deferred Payment
Payment on Deferred Expense
Investment
Address2
Employer
City
State
Zip
First Name
Date
Occupation
Last Name
Address
Expenditure
In-Kind
Loan Repayment
Refund
Reimbursement
Credit Card
3rd Party
Deferred Payment
Payment on Deferred Expense
Investment
Address2
Employer
City
State
Zip
* Expenditure Type (Expenditure, In-Kind, Loan Repayment, Refund, Reimbursement, Credit Card, 3rd Party, Deferred Payment on Deferred Expense,
Investment)Public Officer/Candidate/Other Than Candidate Committee Name Page Total $ ________
CFC-CCDR-FR&TS 1/14
Page 9 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
State of Georgia
Campaign Contribution Disclosure Report
Investments Statement
1. Investment Name
Account #
Institution/Person
Holding Account __________________________________________
Mailing Address __________________________________________
Address2 __________________________________________
. __________________________________________
City State Zip
Value at beginning of reporting period $
Value at end of reporting period $
Difference in value $
Interest Paid Out $
Cash Dividends $
Investment Transactions
Date
Person(s) Involved in Transaction
Value of investment purchased
Value of investment sold
Profit
Loss
2. Investment Name
Account #
Institution/Person
Holding Account __________________________________________
Mailing Address __________________________________________
Address2 __________________________________________
.__________________________________________
City State Zip
Value at beginning of reporting period $
Value at end of reporting period $
Difference in value $
Interest Paid Out $
Cash Dividends $
Investment Transactions
Date
Person(s) Involved in Transaction
Value of investment purchased
Value of investment sold
Profit
Loss
Total value of investments at beginning of reporting period $
Total value of investments at end of reporting period $
Total difference in value $
Page Total Cash Dividends: $
Page Total Interest Paid Out: $
Page Total Profit: $
Page Total Loss: $
CFC-CCDR-FR&TS 1/14
Page 10 of 10
Public Officer/Candidate/Other Than Candidate Committee Name ________________________________________________________ Page ____ of ____
State of Georgia
Campaign Contribution Disclosure Report
Addendum Statement
The Addendum Statement should be used for explanation of any additional information needed to complete an accurate filing of this report.
Information that is to be reported in the body of the report should not be listed on Addendum Statement.
CFC-CCDR-FR&TS 1/14
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Page 1 of 10 CFC-CCDR-FR&TS 114 (Walton County Board of Commissioners)

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Completed 18 July 2020

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