page 1 / 22 received! report of receipts fec 201^1 jan 30....
TRANSCRIPT
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r PAGE 1 / 22
FEC FORM 3
REPORT OF RECEIPTS AND DISBURSEMENTS
For An Auttiorized Committee
R E C E I V E D " !
201̂1 JAN 30. m3-UQ
officrifee}̂ !! CEHTER
1. NAMEOF COMMITTEE (In fuH)
TYPE OR PRINT T Example over the
I Rafael Dagnesses for Congress 2014 I I I I l l l l l l l
If typing, type lines.
12FE4M5
I I I ' I I I I I I _L_L
L I I I i _ J L_L I I I I I I I l l l l l J _ L 65 W Easy Street
ADDRESS (number and street) l l l l l l l l - L - L
Check If different than previously reported. (ACC)
Suite 102 l l l l l l l l
Simi Valley l l l l l J L J U I 93065-6201 I I I
2. FEC IDENTiFiCATiON NUiy/IBER T CITY STATE
3. ISTHIS ra NEW REPORT ^ (N) O R
AMENDED (A)
4. T Y P E O F R E P O R T (Choose One)
(a) Quarteriy Reports:
j T l April 15 Quarterly Report (01)
Q July 15 Quarterly Report (02)
0 October 15 Quarteriy Report (Q3)
0 January 31 Year-End Report (YE)
U Termination Report (TER)
ZIP CODE STATE • DISTRICT
CA 26
(b) 12-Day PRE-Election Report for the:
Primaty (12P) ILJ .General (12G)
Convention (12C) 0 Special (12S)
Runoff (12R)
Election on
M M /. D " D / • • • 1 . ^ U - . . y ^ Y Y Y Y . . . . . .y. n f7 . ._.
in the State of
(c) 30-Day POST-Electlon Report for the:
Q General (30G) Q j Runoff (30R) Special (SOS)
Election on Y Y Y Y In the
State of
5. Covering Period M M
01 . / iJ D D
01 through Y * Y " Y " Y
2013
/ certify that I have examined this Report and to the best of my knowledge and belief it is true, correct and complete.
Type or Print Name of Treasurer . Bryan Burch
Signature of Treasurer Bryan Burch Date
D D
29
NOTE: Submission of false, erroneous, or incomplete information may subject the person signing this Report to the penalties of 2 U.S.C. §437g.
L FE5AN018
Office Use Only
) FEC FORM 3 , (Revised 02/2003)
-
r FEC Form 3 (Revised 02/2003) SUMMARY PAGE of Receipts and Disbursemerits PAGE 2 / 22 Write or Type Committee Name
Rafael Dagnesses for Congress 2014
Report Covering the Period: From: 01 Y " Y Y Y
2013 To: M M
12 D D
31 Y " Y " Y " Y
2013
6. Net Contributions (other than loans)
(a) . Total Contributions (other than loans) (from Line 11(e))...
(b) Total Contribution Refunds (from Une 2D(d))
(c) Net Contributions (other than loans) (subtract Line 6(b) from Line 6(a))
7. Net Operating Expenditures
(a) Total Operating Expenditures (from Une 17)
(b) Total Offsets to Operating Expenditures (from Line 14)
(c) Net Operating Expenditures (subtract Line 7(b) from Line 7(a))
8. Cash on Hand at Close of Reporting Period (from Line 27)
9. Debts and Obligations Owed TO the Committee (Itemize all on Schedule 0 and/or Schedule D)
10. Debts and Obligations Owed BY the Committee (Itemize all on Schedule C and/or Schedule D)
COLUMN A COLUi\AN B This Period Election Cycie-to-Date
20790
20790
11268.01 f
0 \.
—u» u-'-'-u-
11268.01 I
—u u u ?
24521.99 i
20790
20790
For further information contact:
Federal Election Commission 999 E Street, NW
Wasliington, DC 20463
Toll Free 800-424-9530 Local 202-694-1100
L FE5AN018
J
-
r FEC Form 3 (Revised 12/2003) DETAiLED SUMMARY PAGE of Receipts PAGE 3/22 Write or Type Committee Name
Rafael Dagnesses for Congress 2014
M " M / D " D / -y-iry—irrsf-u-y— Report Covering'the Period: From: —91- 2013 To:
M
12 2013
I. RECEiPTS
11. CONTRIBUTIONS (other than loans) FROM:
(a) Individuals/Persons Other Than Political Committees (i) Itemized (use Schedule A)
(ii) Unitemized (iil) TOTAL of contributions .
from individuals ^
03) Political Party Committees (c) other Political Committees
(such as PACs) '.
(d) The Candidate (e) TOTAL CONTRIBUTIONS
(other than loans) (add Unes 11(a)(lii), (b), (c). and (d))..
12. TRANSFERS FROM OTHER AUTHORIZED COMMITTEES
13. LOANS: (a) Made or Guaranteed by the
Candidate
(b) All other Loans (c) TOTAL LOANS
(add Lines 13(a) and (b))
14. OFFSETS TO OPERATING EXPENDITURES (Refunds, Rebates, etc.)
15. OTHER RECEIPTS (Dividends, Interest, etc.)
16. TOTAL RECEiPTS (add Lines 11(e), 12, 13(c), 14, and 15) ^ (Carty Total to Line 24, page 4)
COLUIVIN A COLUIVIN B Total This Period Election Cycle-to-Date
-TJ" U "M-
18700
15000
15000
35790
18700
1970
20670
120
20/90
Z^^ZZZZZ zzzn \. n .n ^-n /yy n.
_^^_000^
35790
L FE5AN018
J
-
r FEC Form 3 (Revised 02/2003) DETAiLED SUMMARY PAGE of Disbursements 1 PAGE 4 / 22 ii. DiSBURSEMENTS
17. OPERATING EXPENDITURES.
18. TRANSFERS TO OTHER AUTHORIZED COMMITTEES,
19. LOAN REPAYMENTS: (a) Of Loans Made or Guaranteed
by the Candidate
(b) Of All Other Loans (c) TOTAL LOAN REPAYMENTS
(add Lines 19(a) and (b))
20. REFUNDS OF CONTRIBUTIONS TO: (a) Individuals/Persons Other
Than Political Committees
(b) Political Party Committees., (c) Other Political Committees
(such as PACs)
(d) TOTAL CONTRIBUTION REFUNDS (add Lines 20(a), (b), and (c))
21. OTHER DISBURSEMENTS,
22. TOTAL DISBURSEMENTS (add Unes 17, 18, 19(c), 20(d), and 21) ^
COLUMN A COLUIVIN B Total This Period Election Cycie-to-Date
11268 BJoT""! If
1 1/—-nr u a iJ"—u 0
1 u IT——XT' u u u l l ^
L TV,—n —ri JT /JV— 0
ZZZZZZZZZZZ 0 _ n f x . . — n 1
=iP=--=.\i-=i;
n n r y n —
11268.01
0
1 ^ ^ ̂ ^ ̂ 0̂ u uT u u u it u
11268.01
iii. CASH SUIVIMARY
23. CASH ON HAND AT BEGINNING OF REPORTING PERIOD.
24 TOTAL RECEIPTS THIS PERIOD (from Une 16, page 3).
25. SUBTOTAL (add Line 23 and Line 24)
26. TOTAL DISBURSEMENTS THIS PERIOD (from Une 22).
27. CASH ON HAND AT CLOSE OF REPORTING PERIOD
(subtract Line 26 from Line 25)
I Ll Ll
I. n ry
° J
35790
35790
11268.01
24521.99^
L FE5AN01B
J
-
SCHEDULE A (FEC Form 3)
ITEMiZED RECEIPTS Use separate schedule(s) for each category of the Deteiled Summary Page
FOR UNE NUMBER: (check only one)
PAGE 5 OF 22
X 11a l i b 11c 12 13a 13b
11d 14 15
Any Information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE On FuH)
Rafael Dagnesses for Congress 2014
A.
Full Name (Last, First, Middle InitiaQ Paul Pagnone
Mailing Address 201 W Palmer Avenue
Apt. C City
Glendale
Stete CA
Zip Code 91204-4002
FEC ID number of contributing federal political committee.
Name of Employer Self
Occupation Real Estate Investor
Receipt For: 2014 Primary P ^ General Other (specify)
Date of Receipt / [irY-a~Ynr-y-tf-v-
2013
Transaction ID: A-CF31
Amount of Each Receipt this Period
500
B.
Full Name (Last, First, Middle InitiaQ David Patterson Date of Receipt
Mailing Address 7659 E Pinnacle Peak Road Suite 100
City Scottsdale
State AZ
Zip Code 85255-6298
2013
Transaction ID: A-CF39
FEC ID number of contributing federal political committee. Amount of Each Receipt this Period
1/—Tj=—a '. ir" •tf'—LT"—'LI—"u—\r
Name of Employer
Quantum of Arizona REALTORS
Receipt For: 2014 ^ Primary P ^ General
Other (specify)
Occupation
Broker
350
Election Cycle-to-Date =TI=5T=
350
c. Full Name (Last, First, Middle InitiaO Omar Salah Date of Receipt
Mailing Address 953 WQQJJ Ranch Parkway
City Siml Valley
State CA
Zip Code
93065-8370
/ / P_12_ 21 2013
Transaction ID : A-CF57
FEC ID number of contributing federal political committee. Amount of Each Receipt this Period
' " 1 3 — ^ Tj" ' LT̂ u - -u ' \ r ' a '~U L
Name of Employer
AIIBaba
Receipt For: 2014 ^ Primary p ^ General
Other (specify)
Occupation Chef
500
Election Cycle-to-Date
500
SUBTOTAL of Receipts This Page (optionaO-
TOTAL This Period (last page this line number only).
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3) ITEMiZED RECEIPTS
Use separate schedule(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check only one)
PAGE 6 OF 22
X 11a l i b 11c 11d 12 13a 13b 14 15
Any Information copied from such Reports and Statements may not be sold or used by any person for the purpose of soiiciting contributions or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (In FuH)
Rafael Dagnesses for Congress 2014
A.
Full Name (Last, First, Middle Initial)
Dr. Racliel Johns Mailing Address 14 Concho Lane
City
Bell Canyon
FEC ID number of contributing federal political committee.
Name of Empioyer SCPMG
Receipt For: 2014 Primary P ^ Generai Other (specify)
State CA
Zip Code 91307-1004
Occupation Physician
Election Cycle-to-Date
-n . n _ . 4.., ' n n , y n_ 250
Date of Receipt
1-JgJI IL21J -> j r - i r -y-Tj-y-Lr>"
2013
Transaction ID: A-CF26
Amount of Each Receipt this Period
250
Full Name (Last, First, Middle InitiaO
g Sammy Saab Mailing Address 1328 Amalfi Drive
City Pacific Palisades
FEC ID number of contributing federal political committee.
Name of Empioyer
Amalfi Health Receipt For: 2014
^ Primary P ^ Generai Other (specify)
Date of Receipt
State CA
Zip Code 90272-4034
D " D
21
Transaction ID: A-CF61
Amount of Each Receipt this Period
Occupation
MD
500 n . n jf- n n D
Election Cycie-to-Date
500 . J \ r U ^ f rJT JT-
c.
Full Name (Last, First, Middle InitiaO
Mr. Todd Wilson Mailing Address 7 Biuefin Court
City Newport Beach
FEC ID number of contributing federai poiiticai committee.
Name of Employer
N/A
Receipt For: 2014 ^ Primary p ^ General
Other (specify)
Date of Receipt
State CA
Zip Code 92663-2777
•|Snri5i"n 12 J U l i J 2013
Transaction ID: A-CF14
Amount of Each Receipt this Period
Occupation RETIRED
500 1 " f .1". P - f . n - .—J «*• "
Election Cycle-to-Date
500 _p f . i ' , - n . . n j . ri p_ •
SUBTOTAL of Receipts This Page (optional).
TOTAL This Period (last page this line number only). I ... n J y . . P • .1 f.
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3) ITEMIZED RECEIPTS
Use separate scheduie(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check only one)
PAGE 7 OF 22
X 11a l i b 11c 12 13a 13b
l i d
14 n 15 Any information copied from such Reports and Statements may not be soid or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any political committee to soiicit contributions from such committee.
\ NAME OF COMMITTEE (In FulO
/ Rafael Dagnesses for Congress 2014
A.
Full Name (Last, First, Middle Initial)
Scott Akerley Mailing Address 5226 Bridgetown Place
City
Westiake Village
State Zip Code CA 91362-4742
FEC ID number of contributing federai poiiticai committee. i Name of Empioyer Glen Oaks Escrow
Receipt For: 2014 Primary P ^ Generai Other (specify)
Occupation CEO
Eiection Cycle-to-Date
Date of Receipt 1a~'ti'-a~
1 12 03 2013 Transaction ID : A-CF43
Amount of Each Receipt this Period
1000 - J l - — F K . — f . . . . n , p-
B.
Full Name (Last, First, Middie InitiaO
Mr. Paul Schiada Mailing Address 1937 N IVIariposa Avenue
Date of Receipt
1'
City Los Angeles
State Zip Code CA 90027-1730
12 2013
Transaction ID: A-CF.19
FEC ID number of contributing federal political committee. Amount of Each Receipt this Period
Name of Empioyer
Self Employed Receipt For: 2014
^ Primary [Z} General Other (specify)
Occupation
Attorney/Investor =fc=5=
500
Election Cycie-to-Date —yl U U~ U' Vi "U • U -
500 -B . .n...,-y-—J-.,—n y .B -.-n_
Full Name (Last, First, Middie InitiaO Date of Receipt
Maiiing Address 11678 Sagewood Drive
City State Zip Code Moorpari< CA 93021-3728
FEC ID number of contributing federai political, committee. jc " » " n . n n .. .n Name of Employer
Vantage Tire Inc.
Occupation Tires Sales
2013
Transaction ID: A-CF27
Amount of Each Receipt this Period
Receipt For:. 2014 ^ Primary p ^ Generai
Other (specify)
500 - J l .n o n..
SUBTOTAL of Receipts This Page (optional).
TOTAL This Period (iast page this line number oniy).
FEC Scheduie A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3)
ITEMIZED RECEIPTS Use separate schedule(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check oniy one)
PAGE 8 OF 22
X 11a l i b 11c 12 13a 13b
l i d
14 15 Any Information copied from such Reports and-Statements may not be soid or used by any'person for the purpose of. soliciting contributions or for commercial purposes, other than using the name and address of any poiiticai committee to soiicit contributions from such committee.
NAME OF COMMITTEE (In FuM) Rafael Dagnesses for Congress 2014
A.
Full Name (Last, First, Middle InitiaO IVIr. Michael Vitar
Mailing Address 21300 Bennuda Street
City
Chatsworth
FEC ID number of contributing federal political committee.
Name of Employer Los Angeles Fire Dept.
Receipt For: 2014 ^ Primary P ^ General
Other (specify)
State CA
Zip Code 91311-1428
Occupation Firefighter
Election. Cycie-to-Date
- a u LT
500 7 ^ — > =
Date of Receipt
1 t2_l / / j i - i r - y - T j - y - i r V l l
2013
Transaction ID : A-CF9
Amount of Each Receipt this Period
500 -Jl . n . . ; n n y . n . r u .
B.
Full Name (Last, First, Middle InitiaO Ms. Elena Millner
Mailing Address 100 Scholz Plaza Penthouse 14
City Newport Beach
FEC ID number of contributing federai poiiticai committee.
Name of Employer
Westwood Receipt For: 2014
^ Primary [^ Generai Other (specify)
Date of Receipt
State CA
Zip Code 92663-1628
2013
Transaction ID: A-CF15
Amount of Each Receipt this Period
Occupation
investor
- t f u U 0 U L
250 „n . n g n n 3 r
Election Cycie-to-Date
250 -Jl ...p ?
c. Fuii Name (Last, First. Middie InitiaO Oscar Khaw
Mailing Address 1473 vista Lane
City Pasadena
FEC ID number of contributing federai poiiticai committee.
Name of Empioyer
Whitehorse & Company
Receipt For: 2014 ^ Primary p ^ Generai
Other (specify)
Date of Receipt
State CA
Zip Code
91103-1938
L-J2_I CJ-y-iry—LTy-"! ^ 20J3 ^ Transaction ID : A-CF34
Amount of Each Receipt this Period
Occupation CPA
500 JT n n n
Election Cycie-to-Date
500 " •? . ? • P ji .. .rt.-_n —a
SUBTOTAL of Receipts This Page (optionaO.
TOTAL This Period (last page this line number only).
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3)
ITEMIZED RECEiPTS Use separate scheduie(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check oniy one)
PAGE 9 OF 22
X 11a 11b 11c 12 13a 13b
11d 14 I lis
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soiiciting contributions or for commercial purposes, other than using the name and address of any poiiticai committee to solicit contributions from such committee.
NAME OF COMMITTEE (in FuiO Rafael Dagnesses for Congress 2014
Full Name (Last, First, Middle Initial) Alexis Saab
Mailing Address 108IO Paramount Boulevard
Suite 201 City
Downey
State CA
Zip Code 90241-3351
FEC ID number of contributing federai political committee.
Name of Employer Law office of Alexis Saab
Receipt For: 2014 X Primary [Z} General
Other (specify)
Occupation Attorney
Election Cycie-to-Date
500
Date of Receipt
12 D U D
16 •V-^ry-iry-u-y-
2013 Transaction ID: A-CF18
Amount of Each Receipt this Period
500 ,j---.jv—. .r-wJ—9.. .n...
B.
Full Name (Last, First, Middle InitiaO Mr. Fred Perez Date of Receipt
Mailing Address 19595 Horace Street
City State Zip Code Chatsworth CA 91311-1927
FEC ID number of contributing federal political committee.
Name of Employer
Mclarens Global Claims Service
Occupation
Vice President
rM~u"isii'" / / 1 1_2 __21_
Transaction ID : A-CF23
/^ount of Each Receipt this Period
Receipt For: 2014 ^ Primary P J General
Other (specify)
250 -Jl ..n .p n n y n-
Eiectlon Cycie-to-Date
250
c.
Fuli Name (Last, First, Middie InitiaO Dr. Yousef Helo
Mailing Address g g ^ Painted Pony Circle
City Simi Vaiiey
State CA
Zip Code 93063-6321
Date of Receipt
^ L J L_20l: 12 - i r y - i n y - {
3
Transaction ID: A-CF8
FEC ID number of contributing federal political committee. —-jj 0
Amount of Each Receipt this Period
Name of Employer
BaxCare group
Receipt For: 2014 Primary p ^ General Other (specify)
Occupation Chiropractor
Eiection Cycie-to-Date
SUBTOTAL of Receipts This Page (pptionai).
TOTAL This Period (iast page this iine number oniy).
1000.00
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3)
ITEMIZED RECEIPTS Use separate schedule(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check oniy one)
PAGE 10 OF 22
X 11a l i b 11c 12 13a 13b
l i d
14 n 15 Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any poiiticai committee to soiicit contributions from such committee.
NAME OF COMMITTEE (in FuN) Rafael Dagnesses for Congress 2014
A.
Full Name (Last, First, Middle Initial) Mr. Mathew Savage
Mailing Address 2192 Hurles Avenue
City
Siml Valley
State CA
Zip Code 93063-2732
FEC ID number of contributing federal political committee.
Name of Empioyer Bank of America
Occupation Corporate Auditor
Receipt For: 2014 ^ Primary P J General
Other (specify)
Date of Receipt j r - u - y - L T - y - u - y -
2013
Transaction ID: A-CF12
Amount of Each Receipt this Period
250
B.
Full Name (Last, First, Middle InitiaO Javier Munoz Date of Receipt
Maiiing Address 9517 Amngton Avenue
City Downey
State CA
Zip Code 90240-3401
M-^nii-i
_!2J ry—iry—LTy—ir -y-
[_^^_2013
Transaction ID: A-CF60
FEC ID number of contributing federal poiiticai committee. Amount of Each Receipt this Period
Name of Employer
Downey Exterminating
Receipt For: 2014 ^ Primary P J General
Other (specify)
Occupation
Sales
-y IW—f^-500
Election Cycie-to-Date
500
Full Name (Last, First, Middle InitiaO ^ Roger J. Alves
Mailing Address 3233 Calle De Debesa
City Camarillo
State CA
Zip Code 93010-8337
Date of Receipt
12 2013
Transaction ID : A-CF52
FEC ID number of contributing federal political committee. Amount of Each Receipt this Period
Name of Employer
Scosche Ind. Inc Receipt For: 2014
^ Primary p ^ Generai Other (specify)
Occupation Executive
1000
Election Cycle-to-Date
1000 • / i n y n n y . , n n P n
SUBTOTAL of Receipts This Page (optionaO.
TOTAL This Period (last page this line number only).
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3)
ITEMIZED RECEiPTS Use separate schedule(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check oniy one)
PAGE 11 OF 22
X 11a l i b 11c l i d 12 13a 13b 14 15
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soiiciting contributions or for commercial purposes, other than using the name and address of any poiiticai committee to. soiicit contributions from such committee.
NAME OF COMMITTEE (In Fuli) Rafael Dagnesses for Congress 2014
A.
Fuil Name (Last, First, Middie InitiaO Mr. Dennis Mangola
Mailing Address 11972 Hertz Avenue
City
Moorpark
State CA
Zip Code
93021 r7130
FEC ID number of contributing federal poiiticai committee.
Name of Empioyer DMC inc.
Occupation Business Consultant
Receipt For: 2014 ^ Primary P ^ Generai
Other (specify)
Date of Receipt
12 1^9 Transaction ID : A-CF33
Amount of Each Receipt this Period
500
B.
Full Name (Last, First, Middle Initial) Aurora Vitar Date of Receipt
Mailing Address 4554 Gainsborough Avenue
City Los Angeles
State Zip Code CA 90027-1229
12 -y—U-y-nr-;—l/'V^
2013
Transaction ID: A-CF54
FEC ID number of contributing federai political committee. ,^3—.n n . .n. . ru
Amount of Each Receipt this Period
Name of Employer
Self Receipt For: 2014
Primary P ^ General Other (specify)
Occupation
Broker. =3t==i:
. 1000 -y—.—Jl n a n_
Electlon Cycie-to-Date
1000
Full Name (Last, First. Middle InitiaO Dennis Saab Date of Receipt
Maiiing Address 10310 Paramount Boulevard
Suite 202 City Downey
State CA
Zip Code
90241-3351
D U D
21 fyi~V^yisry~\r'\r-
2013
Transaction ID: A-CF56
FEC ID numtjer of contributing federal poiiticai committee. i
-\f '. 'u •-•tr'— Amount of Each Receipt this Period
-J '• li •• • a'. ' • u ' i/-
Name of Employer
Self
Receipt For: 2014 ^ Primary p ^ General
Other (specify)
Occupation Attorney
500 J P n . T -
Electlon Cycle-to-Date
500
SUBTOTAL of Receipts This Page (optionaO.
TOTAL This Period (last page this iine number oniy).
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3) ITEMIZED RECEiPTS
Use separate schedule(s) for each category of the Detaiied Summary Page
FOR UNE NUMBER: (check oniy one)
PAGE 12 OF 22
X 11a l i b 11c 12 13a 13b
l i d 14 I 115
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (In FuH)
Rafael Dagnesses for Congress 2014
Full Name (Last, First, Middle Initial)
Srlnlvas Manthena Mailing Address 6717 Aspen Hills Drive
City
Moorpark
State CA
Zip Code 93021-1011
FEC ID number of contributing federal poiiticai committee.
Name of Empioyer Edwards Life Sciences
Receipt For: 2014 ^ Primary { ^ General
Other (specify)
Occupation Sr; Director
Eiection Cycie-to-Date — — U - i l 1 J u—TJ u——Ir—\i-
500 n IT:, ¥ ' "-r-f . . . .*! .1 n-^-n • n 1
Date of Receipt s n j ' M '
12 - y — i r y * \ r y - L r y -
2013
Transaction ID: A-CF59
Amount of Each Receipt this Period
500
B.
Full Name (Last, First, Middie InitiaO
Anna J. Brann Date of Receipt Mailing Address 13337 Pacific Breeze Drive
City Santa Rosa Valley
State CA
Zip Code 93012-8949
12 •y—iry-u -y—u^-
2013
Transaction ID: A-CF69
FEC ID number of contributing federal poiiticai committee. Amount of Each Receipt this Period
Name of Empioyer
Retired Receipt For: 2014
Primary P J General Other (specify)
Occupation
N/A
500 J n y n n_
Election Cycie-to-Date
500
C.
Full Name (Last, First, Middie Initiai)
William E. Robinson Date of Receipt Maiiing Address 12341 Spring Creek Court
City Moorpark
State CA
Zip Code 93021-2724
"Sl-^rsn 12
O U D
21 2013
Transaction ID: A-CF55
FEC ID number of contributing federal poiiticai committee. Amount of Each Receipt this Period
Name of Empioyer
Tire Warehouse Inc. Receipt For: 2014
^ Primary p j Generai Other (specity)
Occupation Sales
500 -SI a
Election Cycle-to-Date
500 , j L _ , , j . , - . . , y —
SUBTOTAL of Receipts This Page (optionai).
TOTAL This Period (iast page this line number only).
1500.00 -y JT n p r
FEC Scheduie A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3)
ITEMIZED RECEiPTS Use separate schedule(s) for each category of the Detaiied Summary Page
FOR UNE NUMBER: (check only one)
PAGE 13 OF 22
X 11a 11b 11c 12 13a 13b
l i d
14 r~ii5 Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the narrie and address of any political committee to soiicit contributions', from such committee.
NAME OF COMMITTEE (in FulO Rafael Dagnesses for Congress 2014
Full Name (Last, First, Middle InitiaO ^ Troy A. Capell
Mailing Address 3232 E Thousand Oaks Boulevard
City
Thousand Oaks
state CA
Zip Code 91362-3446
FEC ID number of contributing federai poiiticai committee.
Name of Employer Quantum Realtors
Receipt For: 2014 ^ Primary P J Generai
Other (specify)
Occupation Realtor
Election Cycle-to-Date
1000
Date of Receipt
Transaction ID: A-CF53
Amount of Each Receipt this Period
Full Name (Last, First, Middle InitiaO g Mr. Wei Zheng Date of Receipt
Maiiing Address 1017 S 2nd Avenue
City Arcadia
State CA
Zip Code 91006-4104
12 D " D
23 -y—u y iiry"~irY"^j
2013
Transaction ID : A-CF29
FEC ID number of contributing" federai poiiticai committee. Cl Amount of Each Receipt this Period Name of Employer
self employed Receipt For: 2014
^ Primary P ^ Generai Other (specify)
Occupation
real estate agent
2600 J . .a , n-
Etection Cycie-to-Date
r ' — V ' ' u-*
2600
c. Fuii Name (l-ast, First, Middie InitiaO Mrs. Virginia Martinez Date of Receipt
Mailing Address 17313 Mayeriing Street
City Granada Hills
State CA
Zip Code 91344-2142
D U D
31 -Y-ijrf-ir?~u~v*-
2013
Transaction ID: A-CF35
FEC ID number of contributing federal pplitical committee. Amount of Each Receipt'this Period
- i , " a • • u il' a t/ "y ' " 'u• •• tf-
Name of Employer
Prospect
Receipt For: 2014 Primary p j Generai Other (specify)
Occupation mortgage banker
500
Eiection Cycle-to-Date
500
SUBTOTAL of Receipts This Page (optionaO.
TOTAL This Period (last page this line number only).
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3)
ITEMIZED RECEiPTS Use separate schedule(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check only one)
PAGE 14 OF 22
X 11a l i b 11c 12 13a 13b
l i d 14 15
Any Information copied from such Reports and Statements may not be sold or used by any person for the purpose of soiiciting contributions or for commercial purposes, other than using the riame and address of any poiiticai committee to soiicit contributions from such committee.-
NAME OF COMMITTEE (In FuH) Rafael Dagnesses for Congress 2014
A.
Full Name (Last, First, Middle Initial) Anthony Santillo
Mailing Address 2128 Crescent Avenue
City
Montrose
State CA
Zip Code 91020-1202
FEC ID number of contributing federai poiiticai committee. 12
=jp===5==3====v===Jr
Name of Empioyer Chicago Title Cmpany
Receipt For: 2014 ^ Primary P ^ Generai
Other (specify)
Occupation Sales
Eiection Cycie-to-Date
-0 ."̂ • T-
Date of Receipt T D 'tl' D 'l
12 15 ~y~£ry~vry* ir^-
2013
Transaction ID: A-CF16
Amount of Each Receipt this Period
1000
Full Name (l-ast. First, Middle InitiaO g Rosemary Allison Date of Receipt
Mailing Address 11521 Sumac Lane
City Santa Rosa Valley
State CA
Zip Code 93012-8859
/ -y*irV"V"y~TrV 1 1_2 06 2013
Transaction ID: A-CF41
FEC ID number of contributing federal political committee. Amount of Each Receipt this Period
Name of Empioyer
Rosematys Consulting
Receipt For: 2014 Primary P ^ General Other (specify)
Occupation
Realtor
500 n n 3 n n
Election Cycle-to-Date
Fuil Name (Last,. First. Middie InitiaO Leonard Taylor Date of Receipt
Maiiing Address 275 N Kalorama Street
Apt. 404 ''__ City Ventura
State CA
Zip Code 93001-2157
c-ery - i
Transaction ID : A-CF46
FEC ID number of contributing federai political committee. Amount of Each Receipt this Period
Name of Employer
Self employed Receipt For: 2014
^ Primary p j Generai Other (specify)
Occupation Certified Signing Specialist
Eiection Cycle-to-Date
250
SUBTOTAL of Receipts This Page (optionaO. . 1750.00
p . ri . g , ^ , . p. . , f . »
-
SCHEDULE A (FEC Form 3) iTEMIZED RECEIPTS
Use separate scheduie(s) for each category of the Detaiied Summary Page
FOR UNE NUMBER: (check oniy one)
PAGE 15 OF 22
X 11a l i b 11c 12 13a 13b
l i d 14 I Il5
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (In FuH)
Rafael Dagnesses for Congress 2014
A.
Full Name (Last, First, Middle InitiaO Richard E. Robinson
Mailing Address 7334 Hogan Street
City
Moorpark
State CA
Zip Code 93021-8737
FEC ID number of contributing federai political committee.
Name of Employer Tire Warehouse inc.
Receipt For: 2014 Primary P ^ General Other (specify)
Occupation Sales
Eiection Cycie-to-Date T7=^—ks—If-
250
Date of Receipt
llnr-ilv'-LJ LJL Transaction ID: A-CF62
Amount of Each Receipt this Period
250
B.
Full Name (Last, First, Middle InitiaO Eric Dominguez Date of Receipt
lyiaiiing Address 342 Rustic Hills Drive
City State Zip Code Simi Vaiiey CA 93065-8221
FEC ID number of contributing federal political committee. MZZZZZZZZZZJ Name of Employer
IMT
Occupation
Sales
"M~ i rM~
12 CZ) j - V - i r y - i r - y - i r y - i j
I _ 2013 fi
Transaction ID : A-CF58
Amount of Each Receipt this Period
Receipt For: 2014 ^ Primaty P ^ General
Other (specity)
500
Election Cycle-to-Date
500
Full Name (Last, First, Middle Initiai)
C. Date of Receipt
Mailing Address
City State Zip Code
"isnniii- 5=| / j"V-TrYnj-y--iry-j
FEC ID number of contributing federai poiiticai committee. Amount of Each Receipt this Period
Name of Employer
Receipt For:
B Primary p j j Generai Other (specify) Occupation
Election Cycie-to-Date
•j> f l , ,a r u
SUBTOTAL of Receipts This Page (optionai).
TOTAL This Period (last page this line number only).
750.00 T • .C •• r 3
—lar- • \ i — - u -
18700.00
FEC Schedule A (Forni 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3)
ITEMiZED RECEIPTS Use separate schedule(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check oniy one)
PAGE 16 OF 22
11a 11b 11c X 12 13a 13b
l i d 14 n 15
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soiiciting contributions or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (In FuH) Rafael Dagnesses for Congress 2014
A.
Full Name (Last, First, Middle InitiaO Rafael Dagnesses-Personal Funds
Mailing Address 35 w Easy Street
Suite 102 City State Zip Code
Simi Valley CA 93065-6201
FEC ID number of contributing federai poiiticai committee.
.1 . . . . • .. ..Q 'n " 'tf u tl 'IS "1
C j H4CA26139 «. . . . . l i t ,—. . . n ... ,n ,,n n n . ,n-_—1
FEC ID number of contributing federai poiiticai committee.
Name of Empioyer Quantum Realtors
Occupation ' Broker
Receipt For: 2014 Primary P ^ Generai Other (specify)
Date of Receipt
/ / 1 12 10 2013
Transaction ID: A-CF7
Amount of Each Receipt this Period
10 . f , n p y " n
Full Name (Last, First, Middle InitiaO Date of Receipt
Mailing Address 35 w Easy Street Suite 102
City State Zip Code Simi Valley CA 93065-6201
FECJD number of contributing federai poiiticai committee. i C i r H4CA26139
1. ' .n . n ^,1 „ n n .. . . n _ , ..jr..
Name of Employer
Quantum Realtors
Occupation
Broker
'ia~i^*i5i'
11 1 / 'y-ify-iry—u-y-*))
2013
Transactiori ID : A-CF48
Amount of Each Receipt this Period
100 £!=5=
Receipt For: 2014 ^ Primary P ^ General
Other (specify)
Full Name (Last, First, Middle InitiaO Rafael Dagnesses-Personal Funds Date of Receipt
Mailing Address 351^ ^gsy Street
Suite 102 City Simi Valley
State CA
Zip Code 93065-6201
ED D U D
24 2013
Transaction ID: A-CF30
FEC ID number of contributing federai political committee. H4CA26139
- j y n II.. IT. . ' ' ' Amount of Each Receipt this Period
Name of Employer
Quantum Realtors
Receipt For: 2014 Primary p j Generai Other (specify)
Occupation Broker
10
Election Cycle-to-Date
15120
SUBTOTAL of Receipts This Page (optionaO.
TOTAL This Period (last page this line number only).
120.00
120.00 -JT n j . _ r u
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE A (FEC Form 3)
ITEMIZED RECEIPTS Use separate schedule(s) for each category -of the Detailed Summary Page
FOR UNE NUMBER: (check only one)
PAGE 17 OF 22
11a l i b 11c
12 X 13a 13b l i d 14 I 115
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose, of soliciting contributions or for commercial purposes, other than using the name and address of any poiiticai committee to solicit contributions from such committee.
NAME OF COMMITTEE (In FuH) Rafael Dagnesses for Congress 2014
Full Name (Last, First, Middle InitiaO Rafael Dagnesses-Personal Funds
Mailing Address 35 yy Easy Street
Suite 102 City
Simi Valley
FEC ID number of contributing federal poiiticai committee.
Name of Empioyer Quantum Realtors
Receipt For: 2014 Primary P J General Other (specify)
State CA
Zip Code
93065-6201
Occupation Broker
Eiection Cycie-to-Date
15120 n I
Date of Receipt
11 at joF9==ir̂ ==u=y=j
2013 !
Transaction ID: A-LL1
Amount of Each Receipt this Period
15000 ,y .n, . y . . 1? '\r
Full Name (Last, First, Middle InitiaO
B. Mailing Address
City
FEC ID number of contributing federai political committee.
Narne of Empioyer
Receipt For: Primary P ^ Generai Other (specify) B
Date of Receipt
State Zip Code 'ZZ 1
i Amount of Each Receipt this Period Occupation
Election Cycie-to-Date
Full Name (Last, First, Middle Initiai)
c. Mailing Address
City
FEC ID number of contributing federal political committee.
Name of Employer
Receipt For: Primary p j Generai Other (specify) a
Date of Receipt
State Zip Code c / |'-v~V-?nrvTry^|j
Amount of Each Receipt this Period
Occupation •Jl—-n-_-ff..,-_n-
Election Cycle-to-Date
-Jl ,. . . . l y ^ y ^ — - j w - j i y — w p-
SUBTOTAL of Receipts This Page (optionaO.
TOTAL This Period (last page this line number only).
-U' ' U U • • U. V~~TJ=
15000.00 —n g. ,J
15000.00
FEC Schedule A (Form 3) (Revised 02/2009)
-
SCHEDULE B (FEC Form 3) ITEMIZED DiSBURSEMENTS
Use separate schedule(s) for each category of the Detaiied Summary Page
FOR UNE NUMBER: (check only one)
PAGE 18 OF 22
X 17 18 19a 20a 20b 20c
19b 21
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (in FuiO
Rafael Dagnesses for Congress 2014
Full Name (Last, First, Middle Initial)
A. EDLT
Mailing Address 1149 W 210th Street
Date of Disbursement
•a ' I 27 2013 City Torrance
State CA
Zip Code 90502-1627
Amount of Each Disbursement this Period
Purpose of Disbursement Photography Fees
Candidate Narrie
Office Sought:
State:
House Senate President
District:
001 400
Transaction ID: B-E-1 Category/
Type
Disbursement For; Primary X
2014 I I Generai
Other (specify)
B.
Full Name (Last, First, Middle Initial)
Gabriela Murillo
Mailing Address 3303 Deaver Drive
Date of Disbursement
PST^ Mi|| / I D " D I / , Y " Y " Y " Y
LM 20,13
City
Corona
State CA
Zip Code
92882-8791 Amount of Each Disbursement this Period
Purpose of Disbursement Campaign Fundraiser
Candidate Name
Office Sought:
State:
House Senate President
District:
001 2973.4
n l l g n n
Transaction ID : B-E-5 Category/
Type Disbursement For: 2014
^ Primary [ [ General Other (specify)
Full Name (Last, First, Middle Initial)
C. Gabriela Murillo Date of Disbursement
Mailing Address 3393 Deaver Drive _ J 2 j D D
30 V Y y Y i
2013 „ i
City Corona
State CA
Zip Code 92882-8791
Amount of Each Disbursement this Period
Purpose of Disbursement Travel: Reimb. Expenses
Candidate Name
Office Sought:
State:
House Senate President
District:
002 240.33^ [
Category/ Type
Transaction ID: B-E-6
Disbursement For: 2014 Primary p ^ General Other (specify)
Original vendors exceeding reporting threshold itemized as memo transactions.
SUBTOTAL of Disbursements This Page (optionaO 3613.73^ '
n JT y, . n A _ . J .r C p n
... n——n J., rL_^y_-, n r̂ j T
FE5AN018 FEC Schedule B (Fomn 3) (Revised 02/2009)
-
SCHEDULE B (FEC Form 3) ITEMIZED DISBURSEMENTS
Use separate schedule(s) for each category of the Detailed Summary Page
FOR UNE NUMBER: (check only one)
PAGE 19 OF 22
X 17 18 19a 19b 20a 20b 20c 21
Any information copied from such Reports and Statements may not tie sold or used by any person for the purpose of soliciting contributions or for commerciai purposes, other than using the name and address of any poiiticai committee to soiicit contributions from such committee.
NAME OF COMMiTTEE (In FuH)
Rafael Dagnesses for Congress 2014
Full Name (Last, First, Middle InitiaO
A. Anedot, Inc.
Mailing Address Srd Street, Suite B
Date of Disbursement
1 12 1 / _ 3 1 _ 1 ' City Baton Rouge
State LA
Zip Code 70801
Purpose of Disbursement Credit Card Processing Fees
Candidate Name
Office Sought:
State:
House Senate President
District:
001
Amount of Each Disbursement this Period
Transaction ID: B-E-37 Category/
Type Disbursement For: 2014
^ Primary . P ^ General Other (specify)
Full Name (Last, First, Middle Initiai)
g Revolvis Consulting, Inc. Date of Disbursement
Mailing Address 7135 Navajo Road Suite P
Enn / I'D""". i J L02 City San Diego
State CA
Zip Code
92119-1695 Amount of Each Disbursement this Period
Purpose of Disbursement Web Design
Candidate Name
Office Sought:
State:
House Senate President
District:
3875
Transaction ID: B-E-2
Disbursement For: 2014 ^ Primary { ^ Generai
Other (specify)
Full Name (Last, First, Middle InitiaO
c. Deluxe Business Solutions Date of Disbursement
Mailing Address 3333 victoria Street N 1M M
L l , 2 j '1 /
City Saint Paul
State MN
Zip Code 55126-2906
Purpose of Disbursement Banking Materials
Candidate Name
Office Sought:
State:
House Senate President
District:
Amount of Each Disbursement this Period
225.22
Transaction ID: B-E-4
Disbursement For: 2014 ^ Primary p ^ General
Other (specify)
SUBTOTAL of Disbursements This Page.(optionaO.
TOTAL This Period (last page this line number only).
J l 4447.02
"IT".—u 1/' ' U'.' • IJ u • u ' "u" ' i r^ 'nr
_p " . . . g . • " . " g . ,rv . .-P. .g_ n_
FEC Schedule B (Fomn 3) (Revised 02/2009)
-
SCHEDULE B (FEC Form 3) ITEMIZED DiSBURSEMENTS
Use separate schedule(s) for each category of the Detaiied Summary Page
FOR UNE NUMBER: (check only one)
PAGE 20 OF 22
X 17 18 19a 20a . 20b 20c
19b 21
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any poiiticai committee, to solicit contributions from such committee.
NAME OF COMMITTEE (In FuH)
Rafael Dagnesses for Congress 2014
Full Name (Last, First, Middle InitiaO
A. Revolvis Consulting, Inc.
Mailing Address 7185 Navaijo Road Suite P
Date of Disbursement
/ D U D /
1 12 31 2013
City San Diego
State CA
Zip Code 92119-1695
Purpose of Disbursement Collaterals
Candidate Name
Office Sought:
State:
House Senate President
District:
001
Amouht of Each Disbursement this Period
3033.59
Transaction ID: B-E-38 Categoty/
Type Disbursement For: 2014
^ __ Primary | [General Other (specify)
><
Full Name'(Last, First, Middle InitiaO
B. Date of Disbursement
Mailing Address -̂ -•̂ ^—il I' • • • f• • • Y " Y y " Y
City state Zip Code Amount of Each Disbursement this Period
Purpose of Disbursement
Candidate Name
Office Sought:
State:
House Senate President
District:
L _ _ J \ _ _ / L . -Ji ,.n , y .1 n . . . c- H-
Category/ Type
Disbursement For: Primary I I Generai
Other (specify)
Full Name (Last, First, Middle InitiaO
C. Date of Disbursement
Mailing Address •fzz Y Y Y Y
City State Zip Code
Purpose of Disbursement
Candidate Name
Office Sought:
State:
House Senate President
District:
Amount of Each Disbursement this Period
•JU,—n ¥ ... a,. . n j n .jv.
Category/ Type
Disbursement For: Primary I I Generai Other (specify)
SUBTOTAL of Disbursements This Page (optional).
TOTAL This Period (iast page this line number only).
••U' 'tl U*-~V—TT-" H" Ll 'TJ I f
3033.59
FE5AN018 FEC Schedule B (Form 3) (Revised 02/2009)
-
SCHEDULE C (FEC Form 3) LOANS
Use separate scheduie(s) for each category of the Detailed Summaty Page
PAGE 21 OF '22
FOR UNE NUMBER: (check only one) 13a
13b
NAME OF COMMITTEE (In Full)
Rafael Dagnesses for Congress 2014 Transaction ID: SC/10-L1
LOAN SOURCE Full Name (Last, First, Middle Initial)
Rafael Dagnesses-Personal Funds [PERSONAL FUNDS]
Mailing Address 65 W Easy Street Suite 102
Election: • 2014 ^ Primary
General Other (specify) Y
City
Siml Valley
state
CA
ZIP Code
93065-6201
Original Amount of Loan Cumulative Payment To Date Balance Outstanding at Close of This Period
15000 .J l nw.- r
15000
TERMS Date Incurred Date Due
11 D D
27 y x y Y
None
Interest Rate
ô!oô Secured
% (apr) ' D Yes No
List All Endorsers or Guarantors (If any) to Loan Source
1. Full Name (Last, First, Middle Initial) Name of Ernpioyer
Mailing Address Occupation
City State ZIP Code
Amount Guaranteed I Outstanding: 1'̂ —
2. Full Name (Last, First, Middle InitiaO Name of Empioyer
Mailing Address Occupation
city State . ZIP Cbde Amount Guaranteed Outstanding:
3. Full Name (Last, First, Middle Initial) Name of Employer
Mailing Address Occupation
City State ZIP Code
Amount Guaranteed Outstanding:
4. Full Name (Last, First, Middle Initial) Name of Employer
Mailing Address Occupation
City State ZIP Code Amount Guaranteed Outstanding:
SUBTOTALS This Period This Page (optional).
TOTALS This Period (last page in this line only).
15000.00
15000.00
Carry outstanding balance only to LINE 3, Schedule D, for this line. If no Schedule D, carry forward to appropriate line of Summary.
FEC Schedule C (Form 3) (Revised 02/2003)
-
SCHEDULE D (FEC Form 3) DEBTS AND OBUGATIONS Excluding Loans
(Use separate schedule(s)
for each numbered line)
I P A G E 22 O F 22 (Use separate
schedule(s) for each
numbered line)
FOR UNE NUMBER: (check only one)
X 9
10
NAME OF COMMITTEE (In FuH)
Rafael Dagnesses for Congress 2014 A. Full Name (Last, First, Middle Initial) of Debtor or Creditor
Revolvis Consulting, Inc.
Mailing Address 7135 Navajo Road Suite P
City State
San Diego
Zip Code CA 92119-1695
Nature of Debt (Purpose): Administrative/Salary/Overhead: Web Design & Hosting Fees
Outstanding Balance Beginning This Period
Payment This Period
. ! - J i . . . > . » g . » » . < j W ^ . - j . ' ^ . - - . ^ j V ^ . J - ^ ^ — R - i - - < ^ i i . i B i 1.
Transaction ID : SD10-DEBT73
Outstanding Balance at Close of This Period
1535
B. Full Name (Last, First, Middle Initial) of Debtor or Creditor
Political Finance Solutions, Inc.
Mailing Address 1022 G Street
Suite B City State Sacramento .
Zip Code CA 95814-0823
Nature of Debt (Purpose): Administrative/Salary/Overhead: Treasury Service
Outstanding Balance Beginning This Period
0
Amount Incurred This Period Payment This Period
Transaction ID : SD10-DEBT72
Outstanding Balance at Close of This Period
C. Full Name (Last, First, Middle Initial) of Debtor or Creditor
Mailing Address
City State Zip Code
Nature of Debt (Purpose):
Outstanding Balance Beginning This Period u i i i i i i V i i ' i U i i ^11
Amount Incurred This Period Payment This Period Outstanding Balance at Close of This Period
z 1) SUBTOTALS This Period This Page (optional),
2) TOTALS This Period (last page this line number only).
3) TOTAL OUTSTANDING LOANS from Schedule C (iast page only) •
4) ADD 2) and 3) and carry fonward to appropriate line of Summary. Page (last page only) 18428.75
FEC Schedule D (Form 3) (Revised 02/2003)
-
."1" - I
cr .1=
v _ CO >
CD S 03
i s JiS 0 3 ^ CO
C D i = 0 3
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L U CO S
RECEIVED
201UAN3O AH S-UQ
FEC MAILCENTtn
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y 3 10 S =
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« iS a gfi
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f|iii!.l5
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-
Federal Election Commission'' ENVELOPE REPLACEMENT PAGE FOR INCOMING DOCUMENTS
The FEC added this page to the end ofthis filing to indicate how it was received.
1 1 Hand Delivered Date of Receipt
1 1 USPS First Class Mail Postmarked
1 1 USPS Registered/Certified Postmarked (R/C)
1 1 USPS Priority Mail | Postmarked
1 1 USPS Priority Mail Express Postmarked
1 1 Postmark Illegible
1 1 No Postmark >•
/ r \ ^ Shipping Date ^ Overnight Delivery Service (Specify): /^oL c>pL I72P(nH
Next Business Day Deliveiy ^
1 1 Received from House Records & Registration Office Date of Receipt
1 1 Received from Senate Public Records Office Date of Receipt
1 1 Received from Electronic Filing Office Date of Receipt
Date of Receipt or Postmarked 1 1 Other (Specify):
PREPARER \holA
DATE PREPARED (8/2013)