Scan 0004

CAMPAIGN REGISTRATION STATEME~

KEf;: COUNT

6N ELI~l~lt1!;1!~rJoNLY

STATE OF WISCONSIN

2009 NOV

GAB-l

'0 AMcD ll; 55 •..

IF A CANDIDATE DOES NOT FILE TIllS STATEMENT BY TIlE DEADLINE FOR FILING NOMINATIO..... N..p1:.].Fi~.. TIlE CANDIDATE'S NAME WILL NOT BE PLACED ON TIlE BALLOT·RE t.1 V ••

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NOTICE: ANY CHANGE OF INFORMATION ON TIllS REGISTRATION STATEMENT MUST BE FILED WITIllN 10 DAYS. IS 1HIS AN AMENDMENT?

0 Yes

lXI

No

1. CANDIDATE AND CANDIDATE COMMITTEE INFORMATION Name of Candidate

party Affiliation

Office Sought (include district or branch number)

Residence Address (number and street)

PrimaIy Date

Candidate Telephone Number (residenCll) -

Election Date

City, State and Zip Code

Campaign Committee Name (if any)

Check One:

[J Personal

Candidate Telephone Number (employment)

[J

Campaign Committee

Support Committee

Candidate Email Address (optional)

Campaign Committee Address (if different than above) - Number, Street, City, State and Zip Code

Telephone Number (if different than above)

2. POLITICAL COMMITTEE INFORMATION (For use ONLY by Political Action Committees, Political Party Committees, Name of Committee

No-r;;

Political Groups, etc.)

(

Address - Number, Street, City, State and Zip Code

c_

141.

~~~\Le\

Telephone Number

~ \ l.<~q,%-\ 'l..\ Sponsoring Organization

- Name and Complete Address

Type of Committee: A.

C!1.

Special Interest Committee (pAC)

llQ

Resident Committee

[J

Nomesident

Committee

B.

o Incorporated Labor Organization - Attach Information Required 0 Political Party Committee o National [J State [J County 0 Other

C.

0

Legislative Campaign Committee - Attach Statement Required by s.II.05(3)(0),

Stats.

D.

[J

Political Group (Referendum)

_

by s.ll.05(3)(n),

Stats.

_

Name of Referendum

E.

0

Recall Committee

_ Name of Officer SlIIbject to Recall

• Attach Statement Required by s.9.1 O(2)(d)

F. G.

0

Independent

[J

Individual - Also, Complete Oath of Independent

GAB-I (Rev. 0912009)

Committee - Also, Complete Oath of Independent

TIDS FORM IS PRESCRIBED

E

Expenditures,

Form EB-6

ditures, Form EB-6

BY: WISCONSIN GOVERNMENT ACCOUNTABILITY BOARD 212 East Washington Avenue, 3'" Floor, P.O. Box 7984, Madison, WI 53707·7984 608-266-8005 http://gab.wi.gID'. Email: gab@wLgnv

3. COMMITTEE TREASURER

(Campaign fmance correspondence is mailed to this address.)

Treasurer's Name

Telephone Number (residence)

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C\\1- 3q~-\~?-'

Address (number and street)

~ 1 ~ 7.. ~.

Telephone Number (employment)

\J..)~~c...\u.('

City, State and Zip Code

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? 3\ \ ()

4. PRINCIPAL OFFICERS OF COMMITTEE AND OTHER CUSTODIANS OF BOOKS AND ACCOUNTS Attach additional listing if necessary. fudicate which officers or committee members are authorized to ftll a vacancy in nomination due to death of candidate by an asterisk(*). This provision only applies to independent and local nonpartisan candidates. s.8.35, Stats.

I,

Name of Financial fustitution

Account Number (Attach list of any additional accounts and deposit boxes, location, type and nmnber, i.e., savings, checking, money market, etc.)

Address (number and street)

City, State and Zip Code

(print full name) certify the information in this statement is true, correct and complete, and that this is the only committee authorized to act on my behalf.

You may be eligible for an exemption from filing campaign fmance reports. Consult the Campaign Finance Instruction and Bookkeeping Manual to determine if the registrant qualifies for exemption. "•.

'¢. This registrant is eligible for exemption.

This registrant will not accept contributions, make disbursements or incur obligations in an aggregate amount of more than $1,000 in a calendar year or accept any contribution or cumulative contributions of more than $100 from a single source during the calendar year, except contributions by a candidate to his or her campaign of $1,000 or less in a calendar year.

_, () . 3) -oj Date

THE ORMATION ON THIS FORM IS REQUIRED BY §§9.10(2)( d), 11.05, 11.06(7), WIS. STATS. FAILURE TO PROVIDE THE INFORMATION MAY SUBJECT YOU TO THE PENALTIES OF §§8.30(2), 11.60, 11.61, 11.66, WIS. STATS.

CAMPAIGN REGISTRATION STATEMENT

HI.LWAljKEE CQUN •Y ELECTION COHMIS fON

STATE OF WISCONSIN GAB-l IF A CANDIDATE DOES NOT FILE THIS STATEMENT BY THE DEADLINE FOR FlUNG NOMINATION p~~ THE CANDIDATE'S NAME WILL NOT BE PLACED ON THE BALLOT.

IS TillS AN AMENDMENT?

0

E I V Ii 0

Yes

1. CANDIDATE AND CANDIDATE COMMITTEE INFORMATION Name of Candidate

Party Affiliation

Office Sought (include district or branch number)

Residence Address (number and street)

Primary Date

Candidate Telephone Number (residence)

City, State and Zip Code

Election Date

Candidate Telephone Number (employment)

Campaign Committee Name (if any)

Check One:

o

Personal Campaign Committee

o

Support Committee

Candidate Email Address (optional)

Campaign Committee Address (if different than above) - Number, Street, City, State and Zip Code

Telephone Number (if different than above)

2. POLITICAL COMMITTEE INFORMATION (For use ONLY by Political Action Committees, Political Party Committees, Political Groups, etc.) Name of Committee

(; (~t-\Jb.1£.

Type of Committee: A.

,9(

Special Interest Committee (PAC)

..s

o

B.

C.

0 0

0

Resident Committee

Nonresident Committee

Incorporated Labor Organization - Attach Information Required by s.II.05(3Xn),

Stats.

Political Party Committee

o National

0

State

0

County

0

Other

_

Legislative Campaign Committee - Attach Statement Required by s.11.05(3)(o), Stats.

,.r Name of Referendum Name of Officer Subject to Recall - Attach Statement Required by s.9.10(2)(d)

F. G.

0 0

Independent Committee - Also, Complete Oath ofIndependent Individual-

GAB-I (Rev. 09/2009)

Expenditures, Form EB-6

Also, Complete Oath of Independent Expenditures, Form EB-6 TillS FORM IS PRESCRIBED BY: WISCONSIN GOVERNMENT ACCOUNTABILITY BOARD 212 East Washington Avenue, 3'" Floor, P.O. Box 7984, Madison.. WI 53707-7984 608-266-8005 http://gab.wi.gov Emai1: [email protected]

(E)..J/)4~-

tvX.

It/Ii /Of
4. PRINCIPAL OFFICERS OF COMMITTEE AND OTHER CUSTODIANS OF BOOKS AND ACCOUNTS Attach additional listing if necessary. Indicate which officers or committee members are authorized to fill a vacancy in nomination due to death of candidate by an asterisk(*). This provision only applies to independent and local nonpartisan candidates. s.8.35, Stats.

Name of Financial Institution

Account Number (Attach list of any additional accounts and deposit boxes, location, type and number, i.e., savings, checking, money market, etc.)

Address (number and street)

City, State and Zip Code

(print full name) certify the information in this statement is true, correct and complete. . Treasurer

I,

~

II / /I I(0 -f---------a

(print full name) certify the information in this statement is true, correct and complete, and that this is the only committee authorized to act on my behalf.

You may be eligible for an exemption from filing campaign fmance reports. Consult the Campaign Finance Instruction and Bookkeeping Manual to determine if the registrant qualifies for exemption.

'¢' This registrant is eligible for exemption.

This registrant will not accept contributions, make disbursements or incur obligations in an aggregate amount of more than $1,000 in a calendar year or accept any contribution or cumulative contributions of more than $100 from a single source during the calendar year, exceph:ontributions by a candidate to his or her campaign of $1,000 or less in a calendar year.

LJ

Thi~O

Iff ::thIn daim to

exemption.

Signature of Candidate or Treasurer

THE INFORMATION ON THIS FORM IS REQUIRED BY §§9.10(2)( d), 11.05, 11.06(7), WIS. STATS. FAILURE TO PROVIDE THE INFORMATION MAY SUBJECT YOU TO THE PENALTIES OF §§8.:30(2), 11.60, 11.61,11.66, WIS. STATS.