seec form 20

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SEEC FORM 20

Itemized Campaign Finance Disclosure Statement

Rev. 1/08

Office Use OnlyCONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION

Electronic Filing

Page 1 of 27

SUMMARY PAGE

1. NAME OF COMMITTEE

2. TREASURER NAME

Elm & Oak PAC

3. TREASURER ADDRESS

4. ELECTION DATE

7. CANDIDATE NAME

8. TYPE OF REPORT

9. PERIOD COVERED

10. CERTIFICATION

5. OFFICE SOUGHT (if applicable) 6. DISTRICT CODE (if applicable)

Title

Title

First

First

MI

MI

Last

Last

Suffix

Suffix

Street Address City State Zip Code

Hector Rivera

196 Lexington Ave New Haven CT 06513

October 10 Filing - Original

Beginning Date Ending Date

09/02/2009 thru 09/30/2009

I hereby certify and state, under penalties of false statement, that all of the information set forth on this

Itemized Campaign Finance Disclosure Statement for the period covered is true, accurate and

complete.

PRINT NAME OF THE SIGNER DATE CERTIFIED

10/13/2009

PENALTY FOR FALSE STATEMENT IS PUNISHABLE BY FINE NOT TO EXCEED $1,000,

OR IMPRISONMENT FOR NOT MORE THAN ONE YEAR, OR BOTH.

SIGNATURE

Electronic Filing Hector Rivera

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SUMMARY PAGE

SEEC FORM 20Itemized Campaign Finance Disclosure Statement

CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION

Rev. 1/08

TOTALS

NAME OF COMMITTEE FILING DUE DATE

COLUMN A

This Period

COLUMN B

Aggregate

11. Balance on hand January 1 of current year for Ongoing and Party

Committees OR Balance on hand from day Committee was formed for all other

12. Balance on hand at the beginning of Reporting Period

13. Contributions received from Individuals (Section A and B)

14. Receipts from Other Committees (Sections C1 + C2)

15. Other Monetary Receipts (Section D-K)

16c. Total Purchases of Advertising in a Program Book (Section L3)

18. Subtotals (add totals in line 12 + line 17 in Column A and in line 11 + 17 in Column B)

19. Expenses Paid by Committee (Section P)

16b. Total Proceeds from Small purchases at Tag Sales, Auctions or Other Sales (Section L2)

20. Balance on hand at close of Reporting Period (Subtract line 19 from line 18)

21. In-Kind Donations not Considered Contributions Received (Section L4)

22. In-Kind Contributions Received (Section M)

23. Refundable Deposit to Telephone Company (Section N)

24. Receipts of Organization Expenditures (Section O)

25. Beginning Loan Balance

25a. + Loans Received (Section D)

25b. + Interest and Penalties on Loan(s)

25c. - Payments on Loan(s)

25d. Total Outstanding Loan Amount

26. Campaign Expenses Paid By Candidate (Section Q)

27. Expenses Incurred on Committee Credit Card (Section R)

28. Expenses Incurred by Committee During this Period but Not Paid (Section S)

28a. Total Outstanding Expenses Incurred by Committee still Unpaid (Section S)

$20,177.00

$10,764.43

$1,500.00 $17,250.00

$0.00 $2,000.00

$0.00 $1,000.00

16a. Total Small Food and Beverage Receipts at Fair (Section L1)

17. Total Monetary Receipts (add totals for lines 13-16c)

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$1,500.00 $20,250.00

$3,847.93 $32,010.50

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00 $0.00

$0.00

$0.00

$12,264.43 $40,427.00

Elm & Oak PAC Original 10/13/2009

$8,416.50 $8,416.50

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I. MONETARY RECEIPTS (Section A-K)

AME OF COMMITTEE FILING DUE DATE


A. Total Contributions from Small Contributors-Received this Period ONLY

(See instructions for definition of Small Contributor) Subtotal Section $0.00

B. Itemized Contributions from Individuals

First Name MI

Martin

Residential Street Address

136 Griswold Rd

City

Wethersfield

State Zip Code

CT 06109

Date Received

09/02/2009

Principal Occupation

Name of Employer

Is this contribution associated with afundraising event listed in Section L1?

Yes

NoIf yes, list Event #

self employed

real estate developer

Is contributor a lobbyist, spouse,

or dependent child of a lobbyist?

Aggregate Contribution

$750.00

Amount of

Contribution

$750.00

Last Name

Kenny

_ Cash _ Money OrderX Personal Check Credit/Debit Card_

Yes_

NoX

If contribution is in excess of $400 to a candidate committee for a chief executive

officer of a municipality does contributor or business he/she associated with have a

contract with said municipality valued at more than $5000?

_

Yes

X

No

Is contributor a principal of state contractor or prospective state contractor?

If yes, indicate which branch or branches of

government the contract is with:

_

Yes No

_

_ Executive Legislative_

_ Payroll Deduction

Method of Contribution

_

X

First Name MI

Salvatore

Residential Street Address

52 Towago Ave

City

Branford

State Zip Code

CT 06405

Date Received

09/02/2009

Principal Occupation

Name of Employer

Is this contribution associated with a

fundraising event listed in Section L1?Yes

NoIf yes, list Event #

Enterprise Plumbing

Owner

Is contributor a lobbyist, spouse,

or dependent child of a lobbyist?

Aggregate Contribution

$750.00

Amount of

Contribution

$750.00

Last Name

Defelice

_ Cash _ Money OrderX Personal Check Credit/Debit Card_

Yes_

NoX

If contribution is in excess of $400 to a candidate committee for a chief executive

officer of a municipality does contributor or business he/she associated with have acontract with said municipality valued at more than $5000?

_

Yes

X

No

Is contributor a principal of state contractor or prospective state contractor?

If yes, indicate which branch or branches of

government the contract is with:

_

Yes No

_

_ Executive Legislative_

_ Payroll Deduction

Method of Contribution

_

X

TOTAL OF ALL CONTRIBUTIONS FROM INDIVIDUALS (Sections A & B) (Total on Line 14 of Summary Page)

Total of Section B $1,500.00

$1,500.00

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I. MONETARY RECEIPTS (Section A-I)

NAME OF COMMITTEE

Elm & Oak PAC

FILING DUE DATE

C1. Contributions from Other Committees

Original 10/13/2009

ame of Committee Name of Treasurer

ddress

City State

Is this contribution associated with a

fundraising event listed in Section L1?

Yes

No

If yes, list Event #

Zip Code Date Received Aggregate Contributions

Amount of Contribution

Total of Section C1

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C2. Reimbursements. Payments. or Surplus Distributions from other Committees

NAME OF COMMITTEE

Elm & Oak PAC

FILING DUE DATE


Original 10/13/2009

me of Committee Name of Treasurer

Address

City State Zip Code

Date ReceivedAmount of Receipt

Reimbursement for shared expense

Payment for goods and services

Surplus Distribution

Total of Section C2

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D. Loans Received this Period





Date Received

Name of Cosigner/Guarantor

Amount

Received

Name of Lender


Is there a

cosigner or

Guarantor of

this loan?

Yes

No

Source of Loan:

Bank

Individual

Candidate

Other

Committee

Total of Section D

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E. Receipts from Entities other than Individuals or Other Committees (Referendum Committees ONLY)



Original 10/13/2009Elm & Oak PAC

Street Address

City State Zip Code

Amount

Received

Name

Date Received

Aggregate Contributions

Total of Section E

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F. Amount Transferred from Affiliated Business Treasury (Business Entity Committees ONLY)




AmountDate of ReceiptIs this transaction associated with a fundraising event listed in Section L1?

Yes No If yes, list Event #

Total of Section F

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G. Amount Transferred from Affiliated Labor Union or Other Organization Treasury (Organization Committees ONLY)




AmountDate of Receipt

Total of Section G

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H. Personal Funds of the Candidate Received this Period (Candidate Committees ONLY)




Amount Method of PaymentDate Received

Cash Personal Check Credit/Debit Card

Total of Section H

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I. Anonymous Contributions




Amountcoins$ 10 bill$ 5 bills$ 1 billsDate Received

Total of Section I

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J. Interest from Deposits in Authorized Accounts

I. Monetary Receipts (Section A-I)



Zip CodeStateCityStreet Address

Date ReceivedName of Institution Amount

Received

Total of Section J

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K. Miscellaneous Monetary Receipts not Considered Contributions




Street Address Cit State Zip Code

Description

Amount

Received

Name Date of Transaction

Total of Section K

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L1. Fundraiser Event Information

II. FUNDRAISING EVENT ACTIVITY



Zip Code

LetterDate of Fundraiser

Fundraising Event # Location: Street Address City State

Was this fundraising event hosted at a personal residence?

Did this fundraiser include items donated by a business entity of up to $100 or items donated by an

individual of u to $50?

Was this fundraiser a tag sale, auction, or other sale of donated items?

Yes No

Yes

Yes

No

No

Description

Were there purchases of advertising space in a program book associated with this is fundraiser?

Did your committee sell food or beverage at a fair or similar mass gathering held within the state?

Yes

Yes

No

No

Subpart 2: (Town Committees and Municipal Candidate Committees ONLY)

Subpart 3: (Town Committees ONLY)

If yes, enterTotal Receipts

If yes, go to Section L4




from small purchases

Subpart 1: (All Committees)

Total of Section L1

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L2. Proceeds from Tag Sale, Auction, or Other Sale of Donated Items




Zip CodeStateCityResidential Street Address

Method of payment:e of the Purchaser Aggregate

Amount of

PurchasesLast Name

First Name MI

Event #

Items Purchased

Personal CheckCash Credit/Debit Card

Date Received

(Individuals ONLY)

Total of Section L2

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L4. In-Kind Donations Not Considered Contributions





Donation given by:Name of the Donor Fair Market

Value of

Donation

Aggregate value for this event

Description of Donation Date Received Event #

Individual Business E ntity

Total of Section L4

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M. In-Kind Contributions

III. NONMONETARY RECEIPTS

NAME OF COMMITTEE


FILING DUE DATE

Street Address

Type of Contributor: Fair Market

Value of this

Contribution

Name

City

State Zip Code

Date Received

Individual

Committee

Is Contributor a lobbyist, spouse, or

dependent child of a lobbyist?Yes

No

If contribution is in excess of $400 to a candidate committee for a chief

executive officer of a municipality does contributor or business he/she is

associated with have a contract with said municipality valued at more

Yes

No

Is this contribution associated with a fundraising event

listed in Section J1?

If yes, list Event#

Yes

No

Description of In-Kind ContributionAggregate contributions

Other

Is contributor a principal of state contractor or prospective state contractor?Yes

No

Total of Section M

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N. Refundable Deposit to Telephone Company


ME OF COMMITTEE FILING DUE DATE


Zip CodeStateCityResidential Street Address

Date ReceivedLast Name (Individuals Only) Amount of

Deposit

Name of Telephone company


First Name MI

Total of Section N

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O. Non-Monetary Receipts of Organization Expenditures Made By

Legislative Leadership, Legislative Caucus, and Party Committee




Street Address Date Notice Received

Description of Donation

Fair Market

Value of

Donation

Name of Committee

City State

Name of Treasurer

Aggregate DonationsZip Code

Purpose of Expenditure

A B C D E

Total of Section O

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P. Expenses Paid By Committee

IV. EXPENDITURES




Description

Amountame of Payee Date of Payment Method of Payment

Pur ose of

Check #

Debit Card

Event #

Candidate(s) Name Office Sought

West Side Democrats

59 Dwight St New Haven COCNTRB

contribution

$2,000.00

X

_

110309/02/2009

Type of Expenditure (if applicable)

_

_

_

_

_ _A B _ C _ D _ E

_

_

Supported

OpposedCoordinated with reimbursement sought

Coordinated without reimbursement sought

Independent

Organization (see Instructions)

(if applicable)

b code

Expenditure


Description


Pur ose of

Check #

Debit Card

Event #


Wachovia Bank

Elm Street New Haven CT 06510BNK

Bank Fee

$19.00

_

X

09/10/2009


_

_

_

_

_ _A B _ C _ D _ E

_

_

Supported

OpposedCoordinated with reimbursement sou ht


Independent

Or anization see Instructions

(if applicable)

b code

Expenditure


Description


Pur ose of

Check #

Debit Card

Event #


Suzanne Mizzoni

93 Miller Ave Milford CT 06460CNSLT

consultant

$250.00

X

_

110409/15/2009


_

_

_

_

_ _A B _ C _ D _ E

_

_

Supported



Independent


(if applicable)

b code

Expenditure

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P. Expenses Paid By Committee

IV. EXPENDITURES




Description


Pur ose of

Check #

Debit Card

Event #


Uzziah McCray

44 Vernon St New Haven CTWAGE

Wage

$50.00

X

_

110809/15/2009


_

_

_

_

_ _A B _ C _ D _ E

_

_

Supported

OpposedCoordinated with reimbursement sou ht

Coordinated without reimbursement sou ht

Independent

Or anization see Instructions

(if applicable)

b code

Expenditure


Description


Pur ose of

Check #

Debit Card

Event #


Sharon Lyons

158 Hightop Cir W New Haven CTWAGE

wage

$100.00

X

_

110609/15/2009


_

_

_

_

_ _A B _ C _ D _ E

_

_

Supported



Independent


(if applicable)

b code

Expenditure


Description


Pur ose of

Check #

Debit Card

Event #


Jarrel Merritt

15 Victory Dr New Haven CTWAGE

wage

$100.00

X

_

110509/15/2009


_

_

_

_

_ _A B _ C _ D _ E

_

_

Supported



Independent


(if applicable)

b code

Expenditure

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Q. Campaign Expenses Paid By Candidate

IV. EXPENDITURES




Description

AmountName of Payee (Name of Vendor who candidate paid directly) Date of PaymentIs Reimbursement

Claimed?

Event #

Purpose of

Expenditure (by code)

Yes No

Total of Section Q

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R. Expenses Incurred on Committee Credit Card

IV. EXPENDITURES




Name of Vendor Amount

Name of Issuing Institution

Date of Transaction

Event #

Type of Credit Card:

Purpose of Expenditure (by code)

Description

Visa Master Card Discover American Express

Other

Total of Section R

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S. Expenses Incurred By Committee but Not Paid During this Period

IV. EXPENDITURES




Description

Name of Creditor Date Incurred Amount Incurred

(Estimate or

Actual)

Purpose of

Expenditure (by

code

Event #

Candidate(s) Name (if applicable) Office SoughtType of Expenditure (if applicable)

A B C D E

Supported



Independent


Total of Section S

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IV. EXPENDITURES



T. Itemization of Reimbursements to Committee Workers and Consultants


Secondary Payee

AmountName of Worker/Consultant Date of Payment Method of Payment

Purpose of Expenditure

Check #

Debit Card

Other Candidate(s) Name Office Sought

Description

Supported

Opposed


Coordinated with reimbursement sought


Independent


A B C D E

Total of Section T

seec form 20

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