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2012District1Smith
OFFICE USE ONLY STATEMENT OF CANDIDATE (Section 106.023, F.S.) (Please print or type) 2012 JAN 30 Art 8:88 1, Chase -Smith candidate for the office of Orlando City Council, District 1 have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. 1/30/12 Date Each candidate must file a statement with the qualifying officer within 10 days after the Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful failure to file this form is a first degree misdemeanor and a civil violation of the Campaign Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida Statutes). DS -DE 84 (05/11) APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES (Section 106.021(1), F.S.) (PLEASE PRINT OR TYPE) NOTE: This form must be on fife with the qualifying officer before opening the campaign account. 2012 ifL 30 Ahl 8:38 OFFICE USE ONLY 1. M CHECK APPROPRIATE BOX(ES): Initial Filing of_Form Re -filing to Change: III Treasurer/Deputy ❑ Depository ❑ Office 0_ Party_ 2. Name of Candidate (in this order: First, Middle, Last) Chase Smith 3. Address (include post office box or street, city, state, zip code) 5395 Dover Village Lane, Unit #7 Orlando, FL 32812 4. Telephone (407 ) 694-4158 5. E-mail address chase@voteforchase.com 6. Office sought (include district, circuit, group number) Orlando City Council, District 1 7. If a candidate for a nonpartisan office, check if applicable: My intent is to run as a Write -In candidate. 8. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a Write -In ITA No Party Affiliation Party candidate. 9.1 have appointed the following person to act as my M Campaign Treasurer Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer Chase Smith 11. Mailing Address 5395 Dover Village Lane, Unit #7 12. Telephone ( 407 ) 694-4158 13. City Orlando 14. County Orange 15. State FL 16. Zip Code 32812 17. E-mail address chase@voteforchase.com 18. 1 have designated the following bank as my A Primary Depository Secondary Depository 19. Name of Bank Chase Bank 20. Address 8255 Lee Vista Boulevard, Ste. A 21. City Orlando 22. County Orange 23. State FL 24. Zip Code 32829 UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE. 25. Date 1/30/2012 26. Signatur C to • X 27. Treasurer's Acceptance of Appointment (f in the blanks an the a Hate block) Chase Smith , do hereby accept the appointment (Please designated above as: 1/30/2012 Print or Type Name) F3 Campaign Treasurer Dep Trees ` X Date Signa f Ca aign easu r or Deputy Treasurer DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. AFFIDAVIT OF FINANCIAL HARDSHIP 2012JAN 30All 8:38 I, Chase Smith , a candidate for the office of Orlando City Council, District 1 do hereby certify, pursuant to Section 99.093, Florida Statutes, that I am unable to pay the 1%o election assessment to qualify for nomination or election to public office because paying the assessment would be an undue burden on my personal financial resources or on the financial resources available to me. UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING AND THAT IT IS A TRUE AND CORRECT STATEMENT. 1/30/12 Date Signature of Cand' 5395 Dover Village Lane, Unit #7 Orlando, FL 32812 Address of Candidate CANDIDATE OATH - CANDIDATE WITH NO PARTY AFFILIATION OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) Chase Smith (PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT * — NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) am a candidate with no party affiliation for the office of Orlando City Council , District 1 , ; I am a qualified elector of (office) (district #) Orange County, Florida; (circuit #) (group or seat #) I am qualified under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or elected; I have qualified for no other public office in the state, the term of which office or any part thereof runs concurrent with the office I seek; and I have resigned from any office from which I am required to resign pursuant to Section 99.012, Florida Statutes; and I will support the Constitution of the United States and the Constitution of the State of Florida. x ( 407) 694-4158 chase@voteforchase.com Sign of Can Telephone Number Email Address 5395 Dover Village Lane, #7 Orlando Address City FL State 32812 Zip Code Candidate's Florida Voter Registration Number (located on your voter information card): 200544239 * Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons with disabilities (see instructions on page 2 of this form): Chayce Smith STATE OF FLORIDA COUNTY OF 01� Sworn to (or affirmed) and subscribed before me this / day of Personally Known: or Produced Identification: Type of Identification Produced: 44024, S nature of Notary P Print, Type, or Stamp ' ommissioned Name of Notary Public /.• --ft.-aaa a DAWN M MARTIN Notary Public - State of Florida • 3 My Comm. Expires Jun 4, 2015 Commission # EE 63655 "4: Bonded Through National Notary Assn, 11 FORM 1 STATEMENT OF FINANCIAL INTERESTS 2011 Please print or type your name, mailing address, agency name, and position below: E LAST NAME -- FIRST NAME -- MIDDLE NAME : Smith Chase FOR OFFICE USE ONLY: MAILING ADDRESS : 5395 Dover Village Lane, Unit #7 ID Code ID No. Conf. Code P. Req. Code CITY : ZIP : COUNTY : Orlando 32812 Orange NAME OF AGENCY : City of Orlando NAME OF OFFICE OR POSITION HELD OR SOUGHT : Orlando City Council, District 1 You aro not limited to the space on the lines on this form. Attach additional sheets, if necessary. CHECK ONLY IF ❑ CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE **** BOTH PARTS OF THIS SECTION MUST BE COMPLETED DISCLOSURE PERIOD: THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR THE PRECEDING TAX YEAR, WHETHER BASED A FISCAL YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING D DECEMBER 31, 2011 OR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR MANNER OF CALCULATING REPORTABLE INTERESTS: THE LEGISLATURE ALLOWS FILERS THE OPTION OF USING REPORTING THRESHOLDS THAT ARE ABSOLUTE REQUIRES FEWER CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED instructions for further details). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (must check U COMPARATIVE (PERCENTAGE) THRESHOLDS DE ❑ DOLLAR VALLIE THRESHOLDS **** ON A CALENDAR YEAR OR ON EITHER (must check one): YEAR: DOLLAR VALUES, WHICH ON PERCENTAGE VALUES (see one): PART A -- PRIMARY SOURCES OF INCOME (If you have nothing to report, you NAME OF SOURCE OF INCOME [Major sources of income to the reporting person - See instructions must write "none" or "n/a") SOURCE'S ADDRESS p. 4] DESCRIPTION OF THE SOURCE'S PRINCIPAL BUSINESS ACTIVITY Orange County Government 201 S Rosalind Avenue, Orlando, FL 32801 Government City of Orlando 400 S Orange Avenue, Orlando, FL 32801 Government PART B -- SECONDARY SOURCES [Major customers, clients, (If you have nothing to report NAME OF BUSINESS ENTITY OF INCOME and other sources of income to businesses , you must write "none" or "n/a") NAME OF MAJOR SOURCES OF BUSINESS' INCOME owned by the reporting person - See ADDRESS OF SOURCE instructions p. 4] PRINCIPAL BUSINESS ACTIVITY OF SOURCE PART C -- REAL PROPERTY [Land buildings owned by the reporting person - See instructions p. 4] (If you have nothing to report, you must write "none" or "n/a") FILING INSTRUCTIONS for when and where to file this form are located at the bottom of page 2. INSTRUCTIONS on who must file this form and how to fill It out begin on page 3. OTHER FORMS you may need to file are described on page 6. Condominium - 5395 Dover Village Lane, Unit #7, Orlando, FL 32812 PART D -- INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions p. 5] (If you have nothing to report, you must write "none" or "n/a") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES PART E — LIABILITIES [Major debts - See instructions p. 5] (If you have nothing to report, you must write "none" or "n/a") NAME OF CREDITOR ADDRESS OF CREDITOR Bank of America P.O. Box 650070, Dallas, TX 75265-0070 Santander Consumer Finance P.O. Box 660633, Dallas, TX 75266-0633 Sallie Mae P.O. Box 9500, Wilkes-Barre, PA 18773-9500 PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions p. 5] (If you have nothing to report, you must write "none" or "n/a") BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3 NAME OF BUSINESS ENTITY ADDRESS OF BUSINESS ENTITY PRINCIPAL BUSINESS ACTIVITY POSITION HELD WITH ENTITY 1 OWN MORE THAN A 5% INTEREST IN THE BUSINESS NATURE OF MY OWNERSHIP INTEREST IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ SIGNATURE (required WHAT TO FILE: After completing all parts of this form including ;Janina and dating jt< send back only the first sheet (pages 1 and 2) for filing. If you have nothing to report in a particular section, you must write "none" or "n/a" in that section(s). NOTE: MULTIPLE FILING UNNECESSARY: Generally, a person who has filed Form 1 for a calendar or fiscal year is not required to file a second Form 1 for the same year. However, a candidate who previously filed Form 1 because of another public position must at least file a copy of his or her original Form 1 when qualifying. DATE SIGNED (required): 2/1/2012 FILING INSTRUCTIONS: WHERE TO FILE: If you were mailed the form by the Commission on Ethics or a County Supervisor of Elections for your annual disclosure filing, return the form to that location. Local officers/employees file with the Supervisor of Elections of the county in which they permanently reside. (If you do not permanently reside in Florida, file with the Supervisor of the county where your agency has its headquarters.) State officers or specified state employees file with the Commission on Ethics, P.Q. Drawer 15709, Tallahassee, FL 32317-5709; physical address: 3600 Maclay Boulevard, South, Suite 201, Tallahassee, FL 32312. Candidates file this form together with their qualifying papers. To determine what category your position falls under, see the "Who Must File" Instructions on page 3. Facsjfniles will not be accepted. WHEN TO FILE: Initially, each local officer/employee, state officer, and specified state employee must file within 30 days of the date of his or her appointment or of the beginning of employment. Appointees who must be confirmed by the Senate must file prior to confirmation, even if that is less than 30 days from the date of their appointment. Candidates for publicly -elected local office must file at the same time they file their qualifying papers. Thereafter, local officers/employees, state officers, and specified state employees are required to file by July 1st following each calendar year in which they hold their positions_ Finally, at the end of office or employment, each local officer/employee, state officer, and specified state employee is required to file a final disclosure form (Form 1F) within 60 days of leaving office or employment. However, filing a CE Form 1F (Final Statement of Financial Interests) does not relieve the filer of filing a CE Form 1 if he or she was in their position on December 31, 2011. FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY (1) Chase Smith OFFICE USE ONLY Name (2) 5395 Dover Village Lane, Unit #7 Address (number and street) Orlando, FL 32812 City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (4) Check appropriate box(es): © Candidate (office sought): Orlando City Council, (3) ID Number: District 1 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED 111 Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT Cover Period: From o1 / 31 / 2012 To IDENTIFIERS 02 / Report 10 / 2012 Report Type G1 [ 1 Original ❑ Amendment El Special Election ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT Cash & Checks $ 5,745.00 (7) Monetary Expenditures Transfers Account Total Monetary EXPENDITURES THIS REPORT $ 3,890.74 Loans $ to Office $ Total Monetary $ 5,745.00 $ 3,890.74 In -Kind $ 650.00 (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date $ 6,395.00 (10) TOTAL Monetary Expenditures To Date $ 3,890.74 (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, correct, and complete. (Type name) Chase Smith I certify that I have examined this report and it is true, correct, and complete. (Type name) Chase Smith ❑ Individual (only for ✓ T surer ❑ Deputy Treasurer Q Candidate ❑ Chairperson (only for PC, PTY & e� coon ..��G"'`orpmun. organization) a' X electioneerin mu _ X Signature Signature / CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) ID. Number 3) Cover Period 01 / 31 /2012 through 02 / 10 / 2012 (4) Page 1 of 5 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 01 / 30 12012 Smith, Chase 5395 Dover Village Lane, Unit #5 Orlando, FL 32812 1 Governme nt CHE 500.00 1 01 / 30 ?012 Reynolds, Greg 322 E Central Blvd., Unit #903 Orlando, FL 32801-4324 1 Propert Y Managem ent CHE 500.00 2 01 / 30 2p12 Weinberg, Linda 1150 Overbrook Dr. Orlando, FL 32804-6728 1 Governm ent CHE 50.00 3 01 / 30 ?012 Edwards, Roger C. 903 Lake Lily Ave. Maitland, FL 32751 I Consult ant CHE 10.00 4 01 / 31 12012 Colon, Angel 9800 Caroline Park Drive Orlando, FL 32832 I Sales CHE 300.00 5 01 / 31 3012 Ruiz, M.D., Pedro 1973 Heritage Estates Drive Orlando, FL 33803 I Physici an CHE 250.00 6 02 / 0] ?012 Haven, Jolynn 7658 Torino Court Orlando, FL 32835 1 Consulta nt CHE 500.00 7 02 / 02 ?012 The Shirt Shop USA, LLC 711 E Lakeshore Dr Ocoee, FL 34761 B Apparel and Printin g Sales CHE 100.00 8 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) I.D. Number 3) Cover Period 01 / 1 / 2012 through 02 10 / 2012 4) Pane 2 5 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 02 / 02 /2012 Herbig, Chase 1315 N Peninsula Avenue New Smyrna Beach, FL 32169 I Insuranc e CHE 500.00 9 02 / 02 »012 Herbig, Star 1315 N Peninsula Avenue New Smyrna Beach, FL 32169 T Insuran ce CHE 500.00 10 02 / 02 2p12 HIG Insurance 890 SR 434 E Longwood, FL 32750 B Insuran ce CHE 500.00 11 02 / 02 ?012 Royals, Joseph 2305 Edgewater Drive, Unit #1702 Orlando, FL 32804 I Banker CHE 100.00 12 02 / 06 /2012 Monaco, Vivien 3697 Grant Blvd. Orlando, FL 32804 I Attorne Y CHE 25.00 13 02 / 08 3012 Sheehan, Patty 1213 Minnesota St. Orlando, FL 32803 I City Commiss ioner CHE 100.00 14 02 / 08 2012 I Spartz, Lindsay 7901 Courtleigh Dr Orlando, FL 32835-5930 I Governme nt CAS 50.00 15 02 / 08 ?012 Spartz, Ryan 7901 Courtleigh Dr Orlando, FL 32835-5930 I Student CAS 50.00 16 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) I.D. Number 3) Cover Period 01 / 31 / 2012 through 02 / 10 2012 (4) Paue 3 5- (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (8) Sequence Number 02 / 08 /2012 Ruffier, John 3701 Lake Sarah Dr Orlando, FL 32804 1 Attorney CHE 100.00 17 02 / 08 012 Young, Jim EXEMPT Orlando, FL 32803 I Law Enforce ment CHE 250.00 18 02 / 08 412 Drake, Susan 1425 Conway Isle Circle Orlando, FL 32809 1 Consult ant CHE 200.00 19 02 / 08 ?012 Grant, Joanne 1243 Lake Willisara Court Orlando, FL 32806 I Managem ent CHE 30.00 20 02 / 08 /2012 Grant, Joanne 1243 Lake Willisara Court Orlando, FL 32806 I Managem ent CHE 25.00 21 02 / 08 3012 Guthrie, Robert 3809 Wethersfield Circle Titusville, FL 32780 I Attorne Y CHE 60.00 22 02 / 08 012 Evers, Whitney E. 8838 Rose Hill Dr. Orlando, FL 32818-6905 I Attorney CHE 35.00 23 02 / 08 ?012 Pierson, Ashley 936 Lamp Post Ln. Lakeland, FL 33809 I Governm ent CHE 25.00 24 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) ID. Number 3) Cover Period 01 / 31 / 2012 through 02 / 10 2012 (4) Page 4 5 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (6) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 02 / 08 /2012 Thomas, Kevin 536 Lake Como Cir. Orlando, FL 32803 I Attorney CHE 250.00 25 02 / 08 /2012 Heller, Steve 1509 E Jefferson Street Orlando, FL 32801 I Sales CHE 100.00 26 02 / 08 2p12 Church Street Entertainment 33 W Church Street Orlando, FL 32801 g Propert y Mgmt/En tertain ment CHE 250.00 27 02 / 08 ?012 Jenkins, Dennis 2107 Tangerine St. Orlando, FL 32803 i Propert y Mgmt. CHE 50.00 28 02 / 08 /2012 Damiani, Lui 603 Strathmore Dr. Orlando, FL 32803--6937 I Governm ent CHE 200.00 29 02 / 08 ?012 Tremont Realty Capital 127 W Church St. Orlando, FL 32801 B Propert Y Managem ent INK Venue Rental 500.00 30 p2 / 08 ?012 Church Street Entertainment 33 W Church St. Orlando, FL 32801 g Property Mgmt/Ent ertainme nt INK Refreshmen is 150.00 31 02 / 09 012 Square, Inc. 901 Mission St. San Francisco, CA 94103 H Credit Card Process ing Co. CHE 10.00 32 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) ID. Number (3) Cover Period 01 31 / 2012 through 02 / 10 / 2012 (4) Page 5 5 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 02 / 09 /2012 Ushkowitz, Eric 5050 Sailwind Cir. Orlando, FL 32810-1839 I Economic Developm ent CHE 100.00 33 02 / 09 12012 Makowski, Susan 9850 Poplar Place Orlando, FL 32827-6840 I CHE 25.00 34 / / / / / / / / / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES Chase Smith (2) I.D. Number (3) Cover Period 01 / 31 / 2012 through 02 / 10 / 2012 (4) Page 1 of 2 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure Type (10) Amendment (11) Amount (6) Sequence Number 01 /30/12 Firriolo, Tony P.O. Box 533325 Orlando, FL 32853 Photography DIS $300.00 1 02 /01 /12 City of Orlando 400 S Orange Avenue Orlando, FL 32801 Filing Fee DIS $958.89 2 02 /04i/12 EMRT Corporation 1256 Vinetree Drive Brandon, FL 33510 Data Provider DIS $180.00 3 02/07/12 OfficeMax 1898 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies DIS $27.99 4 02 /07 /12 Walmart 3838 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies DIS $34.70 5 02 "37/12 Campaign Graphics P.O. Box 4859 Ocala, FL 34478 Yard Signs DIS $1,737.70 6 02 /08/12 l International Press 997 W Kennedy Blvd. Suite Al Orlando, FL 32810 Printing DIS $553.30 7 02 /09/12 Walmart 2600 S Kirkman Road, Orlando, FL 32811 Campaign Office Supplies DIS $10.61 8 DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES Chase Smith (2) I.D. Number (3) Cover Period Q1 / 31 / 2012 through 02 / 10 / 2012 (4) Page 2 of 2 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure Type (1 0) Amendment (11) Amount (6) Sequence Number 02 /09 /12 PayPal 2211 North First Street San Jose, California 95131 Transaction Fees DIS $84.11 9 02 /09/12 Square, Inc. 901 Mission Street San Francisco, CA 94103 Transaction Fees DIS $3.44 10 / / / / / / / / / / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY (1) Chase Smith OFFICE USE ONLY Name (2) 5395 Dover Village Lane, Unit #7 Address (number and street) Orlando, FL 32812 City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (4) Check appropriate box(es): F4 Candidate (office sought): Orland° City Council, (3) ID Number: District 1 E Political Committee • CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence E CHECK IF CCE HAS DISBANDED ■ Party Executive Committee Li Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 02 / 11 / 2012 To 02 / 24 / 2012 Report Type 02 Report ❑ Independent Expenditure Report n Original ❑ Amendment ❑ Special Election (6) CONTRIBUTIONS THIS REPORT Cash & Checks $ 825.00 (7) Monetary Expenditures Transfers Account Total Monetary EXPENDITURES THIS REPORT $ 73.18 Loans $ to Office $ Total Monetary $ 825.00 $ 73.18 In -Kind $ (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date $ 7,220.00 (10) TOTAL Monetary Expenditures To Date $ 3,963.95 (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, correct, and complete. (Type name) Chase Smith I certify that I have examined this report and it is true, correct, and complete. (Type name) Chase Smith ❑ Individual (o. or Tr-asurer ❑ Deputy Treasurer electioneeri - o • u X - i ED Candidate Q Chai • - ► • n (only for PC, PTY & lecti eer' . commun. organization) X ignature ignature CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) I.D. Number Cover Period 02 / 11 / 2012 through 02 24 2012 (4) Page 1 of 2 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 02 / 12 /2012 Baker Barrios 189 S Orange Ave., Ste. 1700, Orlando, FL 32801 B Architec is CHE 100.00 1 02 / 15 012 Skyline Advisors 611 Avalon Blvd. Orlando, FL 32806-4006 B Consult ant CHE 100.00 2 02 / 19 2112 Barbara Cunningham 5401 Halifax Drive Orlando, FL 32812 I CHE 50.00 3 02 / 20 ?012 Robert Cadle 2143 Velvet Leaf Drive Orlando, FL 34761 I CHE 50.00 4 02 / 21 /2012 Nicole McMahon 1921 Blue Fox Ct. Orlando, FL 32825 I Governor ent CHE 100.00 5 02 / 22 ?012 Sue Carpenter 10607 Woodchase Circle Orlando, FL 32836-5886 I Propert y Mgmt. CHE 100.00 6 02 / 22 ?012 Terry Diedrich 514 Raehn Street, Orlando, FL 32806 1 CHE 25.00 7 02 / 22 012 Greg Goddard 31 W Adams St., #1207 Jacksonville, FL 32202 I CHE 50.00 8 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) I.D. Number 3) Cover Period 02 / 11 / 2012 through 02 / 24 / 2012 (4) Page 2 of 2 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 02 / 23 /2012 Scott Glass 2417 Ridgewind Way Windermere, FL 34786 I Attorney CHE 150.00 9 02 / 23 ?012 Kelly Ferris 2043 Glorinda Oak Court Orlando, FL 32820 I Governm ent CHE 100.00 10 / / / / / / / / / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name Chase Smith (2) I.D. Number (3) Cover Period 02 / 11 / 2012 through 02 24 / 2012 (4) Page 1 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure Type (1 0) Amendment (11) Amount (g) Sequence Number 02 /11 /12 Subway 7515 S Orange Avenue, Orlando, FL 32809 Lunch for Campaign Volunteers MON $21.37 1 02 /16 /12 Walmart 3838 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies MON $29.79 2 02 /20 /12 Walmart 3838 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies MON $9.78 3 02 /20/ 12 OfficeMax 1898 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies MON $12.24 4 / / / / / /. / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY (1) Chase Smith OFFICE USE ONLY Name (2) 5395 Dover Village Lane, Unit #7 Address (number and street) Orlando, FL 32812 City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (4) Check appropriate box(es): FA Candidate (office sought): Orlando City Council, (3) ID Number: District 1 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED Li Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee 0 Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 02 / 25 / 2012 To 03 / 09 / 2012 Report Type G3 Report ❑ Independent Expenditure Report EPA Original U Amendment ❑ Special Election (6) CONTRIBUTIONS THIS REPORT Cash & Checks $ 1,825.00 (7) Monetary Expenditures Transfers Account Total Monetary EXPENDITURES THIS REPORT $ 1,008.20 Loans $ to Office $ Total Monetary $ 1,825.00 $ 1,008.20 In -Kind $ (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date $ 9,045.00 (10) TOTAL Monetary Expenditures To Date $ 4,972.15 (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, correct, and complete. (Type name) Chase Smith I certify that I have examined this report and it is true, correct, and complete. (Type name) Chase Smith II Individual (only for E Treasurer ❑ Deputy Treasurer electioneering c n.) E .l Candidate ❑ Chairperson (only for PC, PTY & eri un. organization) X gnature Signature " C A M P A I G N T R E A S U R E R ' S R E P O R T I T E M I Z E D C O N T R I B U T I O N S . r ( 1 ) N a m e C h a s e S m i t h ( 2 ) I . D . N u m b e r 3 C o v e r P e r i o d 0 2 2 5 / 2 0 1 2 t h r o u g h 0 3 0 9 / 2 0 1 2 4 P a n e 1 1 ( 5 ) D a t e ( 7 ) F u l l N a m e ( L a s t , S u f f i x , F i r s t , M i d d l e ) S t r e e t A d d r e s s & C i t y , S t a t e , Z i p C o d e C o n t r i b u t o r T y p e ( 8 ) O c c u p a t i o n ( 9 ) C o n t r i b u t i o n T y p e ( 1 0 ) I n - k i n d D e s c r i p t i o n ( 1 1 ) A m e n d m e n t ( 1 2 ) A m o u n t ( 6 ) S e q u e n c e N u m b e r C a n n e l l a , D a v i d I A t t o r n e y C H E 1 0 0 . 0 0 0 2 / 2 5 / 2 0 1 2 4 4 8 E G o r e S t r e e t O r l a n d o , F L 3 2 8 0 6 1 S h e a f f e r , W i l l i a m 1 A t t o r n e C H E 1 0 0 . 0 0 0 2 / 2 7 0 1 2 6 0 9 E C e n t r a l B l v d Y O r l a n d o , F L 3 2 8 0 1 2 W i n t e r s , M . D . , T o m I P h y s i c i C H E 3 0 0 . 0 0 0 2 / 2 8 2 p 1 2 P . O . B o x 5 6 1 0 2 7 a n O r l a n d o , F L 3 2 8 5 6 - 1 0 2 7 3 W B Q D e s i g n & B E n g i n e e C H E 2 5 0 . 0 0 0 2 / 2 9 ? 0 1 2 E n g i n e e r i n g , I n c . r i n g 2 0 1 N M a g n o l i a A v e n u e , # 2 0 0 4 O r l a n d o , F L 3 2 8 0 1 S E I U F l o r i d a B P A C C H E 5 0 0 . 0 0 0 3 / 0 6 / 2 0 1 2 1 4 6 4 5 N W 7 7 A v e n u e , S t e . 2 0 1 M i a m i L a k e s , F L 5 3 3 0 1 4 B o t w i n , D e b b i e I C H E 7 5 . 0 0 0 3 / 0 8 3 0 1 2 1 2 8 W i s t e r i a A v e . O r l a n d o , F L 3 2 8 0 6 6 0 3 / 0 9 / 2 0 1 2 S h u t t s & B o w e n , L L P 3 0 0 S O r a n g e g A t t o r n e y C H E 5 0 0 . 0 0 7 A v e n u e , S t e . 1 0 0 0 , O r l a n d o , F L 3 2 8 0 1 / / D S - D E 1 3 ( R e v . 0 8 / 0 3 ) S E E R E V E R S E F O R I N S T R U C T I O N S A N D C O D E V A L U E S (1) Name CAMPAIGN TREASURER'S REPORT -- ITEMIZED EXPENDITURES Chase Smith (2) I.D. Number (3) Cover Period 02 / 25 / 2012 through 03 / 09 / 2012 (4) Page 1 of 2 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure Type (10) Amendment (11) Amount (6) Sequence Number 02 /26 /12 Walmart 3838 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies MON $67.46 1 02 /26 /12 ` PMI P.O. Box 698 Marianna, FL 32447 Phone Calls MON $26.10 2 02 /27/12 FedEx Office 6651 S Semoran Blvd., #107 Orlando, FL 32822 Mail Services MON $659.31 3 02 /27/12 Publix 4402 Curry Ford Road Orlando, FL 32812 Postage MON $9.00 4 02 /29 /12 Walmart 3838 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies MON $11.68 5 02 /29/12 Walmart 3838 5 Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies MON $32.96 6 03 /07 /12 Office Max 1898 S Semoran. Blvd. Orlando, FL 32822 Campaign Office Supplies MON $86.01 7 03 /08/ 12 U.S. Post Office 2860 Delaney Avenue Orlando, FL 32806 Postage MON $97.20 8 DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES i (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES Chase Smith (2) I.D. Number (3)CoverPeriod 02 / 25 /2012 through 03 / 09 /2012 (4) Page 2 of 2 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure Type (10) Amendment (11) Amount (8) Sequence Number 03 /0942 PayPal 2211 North First Street San Jose, California 95131 Fees MON $9.48 1 03 /10/12 Publix Postage MON $9.00 2 / / /1 02 / / 02 / / 03 / / 03 / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY (1) Chase Smith OFFICE USE ONLY x' 4 ° „; 'Ma -5 w Name (2) 5395 Dover Village Lane, Unit #7 Address (number and street) Orlando, FL 32812 City, State, Zip Code E CHECK IF ADDRESS HAS CHANGED (4) Check appropriate box(es): © Candidate (office sought): Orlando City Council, (3) ID Number: District 1 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED E Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 03 / 10 / 2012 To 03 / 29 / 2012 Report Type G4 Report ❑ Independent Expenditure Report r Original ❑ Amendment ❑ Special Election (6) CONTRIBUTIONS THIS REPORT Cash & Checks $ 3 650.00 (7) Monetary Expenditures Transfers Account Total Monetary EXPENDITURES THIS REPORT $ 4,549.65 Loans $ to Office $ Total Monetary $ 3,650.00 $ 4,549.65 In -Kind $ 343.57 (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date $ 13,038.57 (10) TOTAL Monetary Expenditures To Date $ 9,521.80 (11) CERTIFICATION ft is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, correct, and complete. (Type name) Chase Smith I certify that I have examined this report and it is true, correct, and complete. (Type name) Chase Smith ❑✓ Individual (on l / Treasurer Deputy Treasurer electioneering m X ❑✓ Candidate ❑ Chairperson (only for PC, PTY & electioneering c un. organization) X Signature Signature CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) I.D. Number 3 Cover Period 03 10 / 2012 through 03 29 / 2012 (4) Passe (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 03 / 11 /12 Ray Jordan 5395 Dover Village Lane, Unit #4 Orlando, FL 32812 1 Semi-Ret ired CHE 100.00 1 03 / 12 012 Fred Leonhardt 1317 Spring Lake Drive Orlando, FL 32804 I Attorne Y CHE 500.00 2 03 / 15 2p12 Q (O 48 � 0 Rit.gejvitirs, (,o0(1344- ttCO$ 01T ( p/v.d.o, Fi.- 3 Pjf -27o8 B Local Union 1365 PAC CHE 500.00 3 03 / 16 ?012 Karen Bishop 5842 Whitley Bay Lane Orlando, FL 32829 I CHE 50.00 4 03 / 16 /2012 The Shirt Shop USA 711 E Lakeshore Drive Ocoee, FL 34761 B Apparel Sales INK "T i` 343.57 5 03 / 16 012 Ana Cruz 11248 Rouse Run Circle Orlando, FL 32817-4550 I CHE 50.00 6 03 / 16 ?012 George Rodon 4866 Berrywood Dr. Orlando, FL 32812 I CHE 50.00 7 03 / 16 ?012 Doug Head 800 Mayfair Circle Orlando, FL 32803 I Communi ty Affairs CHE 100.00 8 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (2) I.D. Number 31 Cover Period 03 / 10 / 2012 through 03 29 , 2012 41 Pane of (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 03 / 18 /2012 Blain Mustain 900 Emerald Drive Chuluota, FL 32766 I CHE 50.00 1 03 18 /2012 Edward Lynum 411 Rock Lake Drive Orlando, FL 32805 I CHE 50.00 2 03 / 19 2Q12 Ana Cruz 1726 E 7th Avenue Tampa, FL 33605 I Consult ing CHE 100.00 3 03 / 19 ?012 Olga Albani--Caporale 10017 Lake District Lane Orlando, FL 32832 I CHE 50.00 4 03 / 21 /2012 James D. Hunt 1231 E Amelia St. Orlando, FL 32803-5403 I Governm ent CHE 100.00 5 03 / 21 7012 Luigi Damiani, Sr. 3606 Lake Underhill Road Orlando, FL 32803 I Retired CHE 100.00 6 03 / 22 ?012 Michael Hodges 936 Lancaster Drive Orlando, FL 32806 I CHE 25.00 7 03 / 22 ?012 Joel Gunter 1815 Formosa Ave. Orlando, FL 32804 I CHE 50.00 8 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (3) Cover Period 03 / 10 2012 through 03 (2) I.D. Number 29 / 2012 (,4) Page 3 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 03 / 22 2012 John G. Peros 1011 N Thornton Avenue Orlando, FL 32803 I Casting CHE 100.00 1 03 22 012 Stephanie Pike 2420 Jamie Circle Orlando, FL 32803 I CHE 25.00 2 03 / 22 2p12 Joseph E. Seagle 7983 Canyon Lake Circle Orlando, FL 32835-5383 I Attorne Y CHE 250.00 3 03 / 22 ?012 Philip Richardson 7983 Canyon Lake Circle Orlando, FL 32835-5383 I Attorne Y CHE 250.00 4 03 / 22 2012 Thearon Scurlock 204 Matilda Court Orlando, FL 32806 1 Marketi ng CHE 100.00 5 03 / 22 3012 Peter B. Lindemann 813 E Kaley St. Orlando, FL 32806 I CHE 50.00 6 03 / 22 012 John D. Ruffier 3701 Lake Sarah Drive Orlando, FL 32804 1 Attorney CHE 100.00 7 03 22 ?012 Taraba Properties Investment, LLC P.O. Box 560639 Orlando, FL 32856-0639 B CHE 50.00 8 DS -DE 13 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Chase Smith (3) Cover Period 03 / 10 / 2012 through 03 29 (2) I.D. Number / 2012 (4) Page 4 of 4 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number Steven J. Heller I Sales CHE 100.00 03 / 22 /2012 1509 E Jefferson Street Orlando, FL 32801 1 Edward Wales I Self CHE 100.00 03 / 24 ,2012 217 E Amelia St. Orlando, FL 32801 Employe d 2 Todd Persons 1 Public CHE 200.00 03 / 26 2p12 950 Oranole Road Maitland, FL Relatia ns 32751 3 At Your Service B Consult CHE 100.00 03 / 29 ?012 7658 Torino Court ing Orlando, FL 32835 Firm 4 Lynette Reynolds I Consult CHE 100.00 03 / 29 /2012 7658 Torino Court ant Orlando, FL 32835 5 Kevin Shaughnessy I Attorne CHE 250.00 03 / 29 3012 1052 Buckwood Dr. Y Orlando, FL 32806 6 / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES Chase Smith (2) I.D. Number (3)CoverPerlod 03 / 10 /2012 through 03 29 / 2012 (4) Page 1 of 3 (9) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure pe Type (10) Amendment (11) Amount (6) Sequence Number 03 /12/12 US Post Office 2860 Delaney Avenue Orlando, FL 32806 Postage MON $48.60 1 03 /14 /12 US Post Office 7360 Curry Ford Road Orlando, FL 32822 Postage MON $45.00 2 03J/15/12 Office Max 1898 S Semoran Blvd. Orlando, FL 32822 Printing MON $27.69 3 03i/15/12 Office Max 1898 S Semoran Blvd. Orlando, FL 32822 Printing MON $26.18 4 03/19/12 US Post Office 10401 Post Office Boulevard Orlando, FL 32862-8499 Postage MON $9.00 5 03 /19/12 PMT P.O. Box 698 Marianna, FL 32447 Phone Calls MON $93.96 6 03 p0/12 f FedEx Office 6651 S Semoran Blvd., #107 Orlando, FL 32822 Printing & Mail Services MON $3,461.51 7 03 /21/12 US Post Office 10401 Post Office Boulevard Orlando, FL 32862-8499 Postage MON $45.00 8 DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES Chase Smith (2) ID. Number (3) Cover Period 03 / 10 / 2012 through 03 / 29 / 2012 (4) Page 2 of 3 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure Type (1 0) Amendment (11) Amount (6) Sequence Number 03 /22/12 Office Max 1898 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies MON $15,98 1 03 /24 /12 Lowe's 3500 S Semoran Blvd. Orlando, FL 32822 Sign Building Materials MON $29.23 2 03 /25)/12 EZ Texting 244 5th Avenue, Suite A224 New York, NY 10001 Texting Service MON $25.00 3 03/26/12 Office Max 1898 S Semoran Blvd. Orlando, FL 32822 Campaign Office Supplies/Print ing MON $46.78 4 03 i'26/12 US Post Office 10401 Post Office Boulevard Orlando, FL 32862-8499 Postage MON $45.00 5 03 /27 /12 PayPal 2211 North First Street San Jose, California 95131 Transaction Fees MON $11.65 6 03 /27 /12 Office Max 1898 S Semoran Blvd. Orlando, FL 32822 Printing MON $20.77 7 03 /27/12 International Press 997 W Kennedy Blvd., Ste. Al Orlando, FL 32810 Printing MON $553.30 8 DS -DE 14 (Rev. 08!03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES Chase Smith (2) I.D. Number (3) Cover Period 03 / 10 / 2012 through 03 / 29 / 2012 (4) Page 3 of 3 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure Type (10) Amendment (11) Amount (6) Sequence Number 29 031/ /12 US Post Office 7360 Curry Ford Road Orlando, FL 32822 Postage MON $45.00 1 / / / / / / / / / / / / / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES