| ITEM 5 |
CONTRIBUTIONS OF OVER $250 RECEIVED IN A CALENDAR YEAR
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List the name and street address of contributors whose total contributions
in any calendar year are more than $250. If the contributor is a committee, also
list the name and address of the committee treasurer. (E.g., A
person who gave $150 and later in the same year gave $125 must be
included). Depending on the period covered by your report (see Item 4) you
may be reporting for only a portion of a calendar year.
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Name and Street Address
or Rural Route of Contributor
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Date of
Contributions
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Total at Start
of Period
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Cash
Contributions
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In-Kind
Contributions
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Unpaid
Pledges
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Total Calendar
Year to Date
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Note: No committee, or other person, shall accept or expend and
anonymous contribution (see definition). If an anonymous contribution
is received, it shall not knowingly be deposited but shall be given
to a tax exempt charitable organization. The charitable organization
receiving the contribution shall provide teh person with a receipt.
(Attach receipt to this filing.)
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