PCC 12 160 6224 o 0 1

GOVERNMENT OF THE DISTRICT OF COLUMBIA OFFICE OF CAMPAIGN FINANCE WASHINGTON, D.C.
20009 REPORT OF RECEIPTS AND EXPENDITURES FOR
CANDIDATE/PRINCIPAL CAMPAIGN COMMITTEE

SUMMARY PAGE
1. Full Name of Committee (Name of Candidate, if Candidate is reporting) Evans 2012 Address (Number and Street) 1402 14th Street, NW City, State and Zip Code Washington DC 20005
2. OCF Identification Number PCCCC2125177 3. Is this report an Amendment? (Yes or No) No
4. TYPE OF REPORT: This REPORT contains activity for:
January 31st Report Primary
SUMMARY 5. Covering Period 08/01/2011 through 01/31/2012
COLUMN A THIS PERIOD
COLUMN B CUM. TO-DATE (PCC)
6. (a) Cash on Hand (January 31st Year End Report Only) (b) Cash on Hand at Beginning of Reporting Period (c) Total Receipts [from Line (16)] (d) Subtotal [add Lines 6(b) and 6(c) for Column A and Lines 6(a) and 6(c) for Column (B)] 7. Total Expenditures (from Line 22) $130,610.87 $8,416.94 $139,027.81
$130,610.87
$313,734.14
$52,466.92
$227,173.25
8. Cash on Hand at Close of Reporting Period [subtract Line 7 from Line 6(d)] 9. Debts and Obligations Owed BY the Committee or the Candidate (itemize all on Schedule D) 10. (a) Loans Owed BY the Committee or the Candidate (itemize all on Schedule E) (b) Loans Owed TO the Committee or the Candidate (itemize all on Schedule E-1)
$86,560.89
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
I certify that I have examined this Report and to the best of my knowledge and belief it is true, correct and complete.
For further information, contact: Office of Campaign Finance Frank D. Reeves Municipal Building 2000 14th Street, NW, Suite 433 Washington, D.C. 20009 (202) 671-0547
James Kane
Type or Print Name of Treasurer (Name of Candidate, if Candidate is reporting)
ELECTRONICALLY CERTIFIED
Signature of Treasurer (Name of Candidate, if Candidate is reporting)
01/31/2012
Date
NOTE: Submission of late, false, erroneous, or incomplete information may subject the person signing this report to the penalties of D.C. Official Code 1-1103.05 and 1-1107.01 (2001 Edition). All previous versions of OCF FORM 16 should no longer be used. OCF FORM 16 Rev. 09/2005
DETAILED SUMMARY PAGE OF RECEIPTS AND EXPENDITURES OCF Form 16, Page 2
1. Full Name of Committee (Name of Candidate, if Candidate is reporting) Evans 2012 REPORT COVERING THE PERIOD 8/1/11 FROM: TO: COLUMN A TOTAL THIS PERIOD $8,100.00 $0.00 $0.00 $0.00 $0.00 $8,100.00 $0.00 1/31/12
I. RECEIPTS
11. CONTRIBUTIONS (OTHER THAN LOANS) FROM: (a) Individuals/Organizations Other Than Political Committees (Schedule A) (b) Political Party Committees (Schedule A-1) (c) Pol. Comms. Other than Pol. Comms. Authorized by the same Can. (Sch A-2) (d) The Candidate (Schedule A-3) (e)Transfers From Authorized Comms. of the Can. identified in this Report (Sch A-4) (f) Total Contributions - Other Than Loans [add lines 11(a), (b), (c), (d), and (e)] 12. SALES AND COLLECTIONS (Schedule C) 13. LOANS (a) Loans owed BY The Candidate/PCC or the Committee (Schedule E) (b) Loans owed TO The Candidate/PCC or the Committee(Schedule E-1) (c) Total Loans [add Lines 13(a), and 13(b)] 14. OTHER RECEIPTS (Dividends, Interest, etc.) (Schedule A-5) 15. OFFSETS TO OPERATING EXPENDITURES (Schedule A-6) 16. TOTAL RECEIPTS [add Lines 11(f), 12, 13(c), and 14 and 15]
COLUMN B CUMULATIVE YEAR-TO-DATE $309,400.12 $1,250.00 $2,450.00 $0.00 $0.00 $313,100.12 $0.00 11(a) 11(b) 11(c) 11(d) 11(e) 11(f)
12
$0.00 $0.00 $0.00 $0.00 $316.94 $8,416.94
$0.00 $0.00 $0.00 $0.00 $634.02 $313,734.14
13(a) 13(b) 13(c) 14 15 16
II. EXPENDITURES
17. OPERATING EXPENDITURES (Schedule B) 18. TRANSFERS TO OTHER AUTHORIZED COMMITTEES (Schedule B-1) 19. LOAN REPAYMENTS: (a) Of Loans owed BY The Candidate/PCC or the Committee (Schedule E) (b) Of Loans owed TO The Candidate/PCC or the Committee (Schedule E-1) (c) Total Loan Repayments [add Lines 19(a) and 19(b)] 20. REFUNDS OF CONTRIBUTIONS TO: (a) Individuals/Organizations Other Than Political Committees (Schedule B-2) (b) Political Party Committees (Schedule B-3) (c) Other Political Committees (Schedule B-4) (d) Total Contribution Refunds [add Lines 20(a), (b), and (c)] 21. OTHER EXPENDITURES (a) Independent Expenditures (Schedule B-5) (b) Offsets to Receipts (Schedule B-6) (c) Total Other Expenditrures [add Lines 21(a), and 21(b)] 22. TOTAL EXPENDITURES [add Lines 17, 18, 19(c), 20(d), and 21(c)] $0.00 $0.00 $0.00 $52,466.92 $0.00 $0.00 $0.00 $227,173.25 21(a) 21(b) 21(c) 22 $0.00 $0.00 $0.00 $0.00 $500.00 $0.00 $0.00 $500.00 20(a) 20(b) 20(c) 20(d) $52,466.92 $0.00 $226,673.25 $0.00 17 18
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
19(a) 19(b) 19(c)
III. CASH SUMMARY
23. CASH ON HAND AT BEGINNING OF REPORTING PERIOD 24. TOTAL RECEIPTS THIS PERIOD (from Line 16) 25. SUBTOTAL (add Lines 23 and 24) 26. TOTAL EXPENDITURES THIS PERIOD (from Line 22) 27. CASH ON HAND AT CLOSE OF REPORTING PERIOD (subtract Line 26 from Line 25)
$130,610.87 $8,416.94 $139,027.81 $52,466.92 $86,560.89
OCF FORM 16
SCHEDULE A
Page 1 of 5
for Line Number 11a
ITEMIZED RECEIPTS FROM INDIVIDUALS/ORGANIZATIONS OTHER THAN POLITICAL COMMITTEES Any information copied from such Reports or Statements may not be sold or used by any person for the purpose of soliciting contributions, or for commercial purposes.
Full Name of Committee (Name of Candidate, if Candidate is reporting) Evans 2012 1. Full Name, Mailing Address and Zip Code Mary Brown 1110 P Street, NW Washington DC 20005 Contributor Type
Individual
Name and Address of Employer Cisco systems 1300 Pennsylvania Ave, NW Washington DC 20004 Occupation
Attorney
Date
Amount of Each Contribution This Period

$100.00
01/11/2012
Receipt For
Primary Election
Contribution Type
CH
Aggregate Year-To-date
$100.00
2. Full Name, Mailing Address and Zip Code Pfizer 235 East 42nd Street New York NY 10017 Contributor Type
Business
Name and Address of Employer
Date

$500.00
Occupation Contribution Type

CH
01/11/2012
Receipt For
Primary Election
$500.00
3. Full Name, Mailing Address and Zip Code Dan Montgomery 620 Boyle Lane McLean VA 22102 Contributor Type
Individual
Name and Address of Employer Clark Enterprises 7500 Old Georgetown Road, 15th Floor Bethesda MD 20814 Occupation
Attorney
Date

$500.00
01/11/2012
Receipt For
Primary Election
Contribution Type
CH
$500.00
4. Full Name, Mailing Address and Zip Code Virtual Premise 1331 L Street, NW Washington DC 20005 Contributor Type
Business
Date

$500.00

CH
01/11/2012
Receipt For
Primary Election
$500.00
5. Full Name, Mailing Address and Zip Code Lynda Camalier 1629 K Street, NW Washington DC 20006 Contributor Type
Individual
Name and Address of Employer Self

Washington DC
Date

$500.00
Occupation
Interior Designer
01/11/2012
Receipt For
Primary Election
Contribution Type
CH
$500.00
OCF FORM 16
SCHEDULE A
Page 2 of 5
for Line Number 11a
Full Name of Committee (Name of Candidate, if Candidate is reporting) Evans 2012 6. Full Name, Mailing Address and Zip Code Peter Beler 700 New Hampshire Avenue, NW Washington DC 20037 Contributor Type
Individual
Name and Address of Employer The Prime Rib 2020 K Streets, NW Washington DC 20006 Occupation
Owner
Date

$500.00
01/11/2012
Receipt For
Primary Election
Contribution Type
CH
$500.00
7. Full Name, Mailing Address and Zip Code First Potomac Realty Investment 7600 Wisconsin Avenue, 11th Floor bethesda MD 20814 Contributor Type
Business
Date

$250.00

CH
01/25/2012
Receipt For
Primary Election
$250.00
8. Full Name, Mailing Address and Zip Code Anthony Washington 4502 - 17th Street, NW Washington DC 20011 Contributor Type
Individual
Date

$250.00
Washington DC

CH
01/25/2012
Receipt For
Primary Election
$250.00
9. Full Name, Mailing Address and Zip Code Malcolm Peabody 2811 Dumbarton Street, NW Washington DC 20037 Contributor Type
Individual
Name and Address of Employer Peabody Corporation 2120 16th Street, NW Washington DC 20009 Occupation
President
Date

$250.00
01/31/2012
Receipt For
Primary Election
Contribution Type
CH
$250.00
10. Full Name, Mailing Address and Zip Code Jumbo Seafood Restaurant 619 H Street, NW Washington DC 20001 Contributor Type
Business
Date

$500.00

CH
01/31/2012
Receipt For
Primary Election
$500.00
OCF FORM 16
SCHEDULE A
Page 3 of 5
for Line Number 11a
Full Name of Committee (Name of Candidate, if Candidate is reporting) Evans 2012 11. Full Name, Mailing Address and Zip Code Tony Cheng's Mongolian Restaurant 619 H Street, NW Washington DC 20001 Contributor Type
Business
Date

$500.00

CH
01/31/2012
Receipt For
Primary Election
$500.00
12. Full Name, Mailing Address and Zip Code Chi Jung Chiang 811 7th Street, NW Washington DC 20001 Contributor Type
Individual
Name and Address of Employer Tony Chengs Restaurant 811 7th Street, NW Washington DC 20001 Occupation Contribution Type
CH
Date

$500.00
01/31/2012
Receipt For
Primary Election
$500.00
13. Full Name, Mailing Address and Zip Code Shu Feng Chiang 811 7th Street, NW Washington DC 20001 Contributor Type
Individual
Name and Address of Employer Tony Cheng's Mongolian Restaurant 811 7th Street, NW Washington DC 20001 Occupation Contribution Type
CH
Date

$500.00
01/31/2012
Receipt For
Primary Election
$500.00
14. Full Name, Mailing Address and Zip Code Stephanie Cheng 111 N Cleveland Street Arlington VA 22201 Contributor Type
Individual
Name and Address of Employer Tony Cheng Restaurant 619 H Street, NW Washington DC 20001 Occupation Contribution Type
CH
Date

$500.00
01/31/2012
Receipt For
Primary Election
$500.00
15. Full Name, Mailing Address and Zip Code AYT, Inc. 6520 Central Avenue Capitol Heights MD 20743 Contributor Type
Business
Date

$500.00

CH
01/31/2012
Receipt For
Primary Election
$500.00
OCF FORM 16
SCHEDULE A
Page 4 of 5
for Line Number 11a
Full Name of Committee (Name of Candidate, if Candidate is reporting) Evans 2012 16. Full Name, Mailing Address and Zip Code Richard Gersten 3526 Edmunds Street, NW Washington DC 20007 Contributor Type
Individual
Name and Address of Employer Urban Igloo, LLC 1808 I Street, NW Washington DC 20006 Occupation
President and CEO
Date

$500.00
01/12/2012
Receipt For
Primary Election
Contribution Type
Credit Card
$500.00
17. Full Name, Mailing Address and Zip Code Clyde Shorey 3033 West Lake Keys Washington DC 20007 Contributor Type
Individual
Name and Address of Employer Retired

Washington DC
Date

$250.00
Occupation
Retired
01/31/2012
Receipt For
Primary Election
Contribution Type
CH
$250.00
18. Full Name, Mailing Address and Zip Code Kimberly Ray 2158 Vittoria Court, Unit 61 Bowie DC 20721 Contributor Type
Individual
Name and Address of Employer Aspen Of DC 1101 15th Street NW, Suite 202 Washington DC 20005 Occupation
Consultant
Date

$500.00
01/31/2012
Receipt For
Primary Election
Contribution Type
CH
$500.00
19. Full Name, Mailing Address and Zip Code JLR Construction Group LLC 4933 12th Street NE Washington DC 20017 Contributor Type
Corp.
Date

$500.00

CH
01/31/2012
Receipt For
Primary Election
$500.00
TOTAL This Period (Aggregate of all receipts pages)
$8,100.00
OCF FORM 16
SCHEDULE A-6
Page 5 of 5
for Line Number 15
OFFSETS TO OPERATING EXPENDITURES (REFUNDS AND REBATES Any information copied from such Reports or Statements may not be sold or used by any person for the purpose of soliciting contributions, or for commercial purposes.
Full Name of Committee (Name of Candidate, if Candidate is reporting) Evans 2012 20. Full Name, Mailing Address and Zip Code Katherine Stocks 829 Quincy Street, NW #210 Washington DC 20001 Contributor Type
Refund
Date

$316.94

Refund
01/09/2012
Receipt For
Primary Election
$316.94
TOTAL This Period (Aggregate of all receipts pages)
$316.94
OCF FORM 16
SCHEDULE B ITEMIZED OPERATING EXPENDITURES
Page 1 of 9
for Line Number 17
Any information copied from such Reports or Statements may not be sold or used by any person for the purpose of soliciting contributions, or for commercial purposes.
Full Name of Committee (Name of Candidate, if Candidate is reporting) Evans 2012 1. Full Name, Mailing Address and Zip Code
The Current Newspapers/Voice PO Box 40400 Washington DC 20016 12/21/2011
Date
Amount of Each Expenditure This Period

$1,024.80
Purpose of Expenditure Advertising Expenditure For:

Primary Election
Occupation
2. Full Name, Mailing Address and Zip Code

202 Design 3900 Military Rd., NW Washington DC 20015
Date

$5,235.77
12/12/2011

Primary Election
Occupation

Citizen's Association of Georgetown 1365 Wisconsin Avenue NW, Suite 200 Washington DC 20007
Date

$1,500.00
12/14/2011

Primary Election
Occupation

Borderstan Media LLC 1626 15th Street NW #101 Washington DC 20009
Date

$2,160.00
12/14/2011

Primary Election
Occupation
OCF FORM 16
Page 2 of 9
for Line Number 17
Intowner Publishing Corp. 1730-B Corcoran Street NW Washington DC 20009 12/14/2011
Date

$1,575.00

Primary Election
Occupation

Bynum Thompson Ryer 2120 L Street, NW, Suite 305 Washington DC 20037
Date

$2,500.00
12/14/2011

Primary Election
Occupation

Jim Abdo Development 1404 14thStreet NW Washington DC 20005
Date

$283.66
12/14/2011
Purpose of Expenditure Utility Expenditure For:

Primary Election
Occupation

The Current Newspapers/Voice PO Box 40400 Washington DC 20016
Date

$1,024.80
12/14/2011

Primary Election
Occupation
OCF FORM 16
Page 3 of 9
for Line Number 17
Katherine Stocks 829 Quincy Street NW Washington DC 20011

Self 829 Quincy Street NW Washington DC 20011
Date

$2,750.00
12/14/2011
Purpose of Expenditure Consultant Expenditure For:

Primary Election
Occupation Consultant

4 Imprint 101 Commerce Street, PO Box 320 Oshkosh WI 54901
Date

$263.42
12/14/2011
Purpose of Expenditure Campaign Materials Expenditure For:

Primary Election
Occupation

Mattox Photography 5021 Seminary Road, Suite 130 Alexandria VA 22311
Date

$750.00
12/19/2011

Primary Election
Occupation

202 Design 3900 Military Rd., NW Washington DC 20015
Date

$552.50
12/22/2011

Primary Election
Occupation
OCF FORM 16
Page 4 of 9
for Line Number 17
Date

$1,024.80

Primary Election
Occupation


Date

$2,750.00
12/28/2011

Primary Election

Staples 3100 14th st., NW St.115 Washington DC 20015
Date

$133.55
12/28/2011
Purpose of Expenditure Printing Expenditure For:

Primary Election
Occupation

Dupont Circle Citizens Association 9 Dupont Circle Washington DC 20036
Date

$500.00
12/23/2011

Primary Election
Occupation
OCF FORM 16
Page 5 of 9
for Line Number 17
Jim Abdo Development 1404 14thStreet NW Washington DC 20005 12/23/2011
Date

$4,375.00
Purpose of Expenditure Rental Expenditure For:

Primary Election
Occupation

Clearwire DEPT CH 14365 Palantine IL 60055
Date

$94.91
01/02/2012
Purpose of Expenditure Phone Bill Expenditure For:

Primary Election
Occupation

Date

$1,024.80
01/04/2012

Primary Election
Occupation

Office Depot 4455 Connecticute Avenue, NW Washington DC 20008
Date

$440.00
01/09/2012
Purpose of Expenditure Postage Expenditure For:

Primary Election
Occupation
OCF FORM 16
Page 6 of 9
for Line Number 17
Georgetown Dish 3333 N Street NW #1 Washington DC 20007 01/10/2012
Date

$1,000.00

Primary Election
Occupation

LSG Strategies 2120 L St NW # 305 Washington DC 20037
Date

$2,500.00
01/10/2012

Primary Election
Occupation

Date

$116.33
01/10/2012
Purpose of Expenditure Utility Expenditure For:

Primary Election
Occupation

Date

$1,024.80
01/11/2012

Primary Election
Occupation
OCF FORM 16
Page 7 of 9
for Line Number 17

Date

$2,750.00
01/15/2012

Primary Election

Sprint P.O. Box 660075 Dalls TX 75266
Date

$56.00
01/09/2012
Purpose of Expenditure Phone Bill Expenditure For:

Primary Election
Occupation

Jack Evans 3141 P Street NW Washington DC 20007

Council of the District of Columbia 1350 Pennsylvania Avenue, NW Washington DC 20004
Date

$208.25
01/13/2012
Purpose of Expenditure Catering/Refreshments Expenditure For:

Primary Election
Occupation Councilmember

Date

$1,024.80
01/18/2012

Primary Election
Occupation
OCF FORM 16
Page 8 of 9
for Line Number 17
Date

$1,024.80

Primary Election
Occupation

Office Depot 4455 Connecticute Avenue, NW Washington DC 20008
Date

$26.49
01/29/2012
Purpose of Expenditure Supplies Expenditure For:

Primary Election
Occupation

Date

$4,375.00
01/30/2012
Purpose of Expenditure Rental Expenditure For:

Primary Election
Occupation


Date

$2,750.00
01/30/2012

Primary Election
OCF FORM 16
Page 9 of 9
for Line Number 17
Mosaic 4801 Veiwpoint Pl., Cheverly MD 20781 01/30/2012
Date

$5,624.94
Purpose of Expenditure Printing Expenditure For:

Primary Election
Occupation

Rally dba Piryx Incorporated 144 2nd St. 1st Floor San Francisco CA 94105
Date

$22.50
01/31/2012
Purpose of Expenditure Bank Fees Expenditure For:

Primary Election
Occupation
TOTAL This Period (Aggregate of all expenditure pages)
$52,466.92
OCF FORM 16
SCHEDULE C ITEMIZED RECEIPTS - SALES AND COLLECTIONS Page 1 of 1
for Line Number 12
Full Name of Committee (Name of Candidate, if Candidate is reporting)
Evans 2012
TOTAL SUM OF PROCEEDS DURING THE REPORTING PERIOD FROM:
08/01/2011
TO
01/31/2012
1. Sale of Tickets (list by event below)* 2. Mass Collections (list by event below) 3. Sale of Items 4. Total cash/check contributions of $49.00 or less from individuals TOTAL (carry forward to Line 12 of Detailed Summary Page)
$ $ $ $ $
LIST OF SALES AND COLLECTIONS BY EVENT
Date of Event (Month, Day, Year)
Type of Event
Amount From Sale of Tickets This Period
Amount From Mass Collections This Period
TOTAL THIS PERIOD (Aggregate the subtotal of all Sales and Collections Page
* After completion of the above list by event, use the appropriate sub-schedule of Schedule A to list the date, full name and mailing address (occupation and principal place of business, if any) of each person who has purchased one or more tickets for events such as dinners, luncheons, rallies, and similar fund-raising events during this reporting period, and whose ticket purchases are in excess of $ 49, or whose total ticket purchases to date for the calendar year (aggregate) are in excess of $49. Attach the appropriate sub-scheduleSchedule A to this Schedule, and identify it as Part 2 of Schedule C.
SCHEDULE D
DEBTS AND OBLIGATIONS Excluding Loans OCF FORM 16 Page 1 of 1
Evans 2012
Outstanding Balance Beginning This Period
Amount Incurred This Period
Payment This
Outstanding Balance at Close of This Period
1. Full Name, Mailing Address and Zip Code of Debtor or Creditor
Nature of Debt (Purpose)
TOTAL This Period (Aggregate the subtotal of all Debts and Obligations Schedules and carry forward to line 9 of the Summary Page)
SCHEDULE E
LOANS OWED BY THE COMMITTEE OR THE CANDIDATE FORM 16

Page 1 of 1
for Line Number 19b
Evans 2012
A. Full Name, Mailing Address and Zip Code
of Loan Source
Original Amount of Loan
Payment this Period
Cumulative Payment to Date
Balance Outstanding at Close of This Period
Election:
Terms:
Date Incurred
Date Due:
Interest Rate:
% (apr)
Secured
List All Endorsers or Guarantors (if any)
Full Name, Mailing Address and Zip Code
Name of Employer
Occupation
Guaranteed Amount Outstanding
SUBTOTAL this period this page TOTALS this period (Aggregate the Subtotals from all Loan Schedules) Carry outstanding Loan Balance forward to Line 10(a) on Summary Page.

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GOVERNMENT OF THE DISTRICT OF COLUMBIA OFFICE OF CAMPAIGN FINANCE WASHINGTON, D.C.

20009 REPORT OF RECEIPTS AND EXPENDITURES FOR

CANDIDATE/PRINCIPAL CAMPAIGN COMMITTEE

2. OCF Identification Number PCCCC2125177 3. Is this report an Amendment? (Yes or No) No

4. TYPE OF REPORT: This REPORT contains activity for:

January 31st Report Primary

SUMMARY 5. Covering Period 08/01/2011 through 01/31/2012

COLUMN A THIS PERIOD

COLUMN B CUM. TO-DATE (PCC)

$0.00 $0.00 $0.00 $0.00 $316.94 $8,416.94

$0.00 $0.00 $0.00 $0.00 $634.02 $313,734.14

13(a) 13(b) 13(c) 14 15 16

$0.00 $0.00 $0.00

$0.00 $0.00 $0.00

19(a) 19(b) 19(c)

III. CASH SUMMARY

$130,610.87 $8,416.94 $139,027.81 $52,466.92 $86,560.89

for Line Number 11a

Amount of Each Contribution This Period

Name and Address of Employer

Amount of Each Contribution This Period

Occupation Contribution Type

Amount of Each Contribution This Period

Name and Address of Employer

Amount of Each Contribution This Period

Occupation Contribution Type

Name and Address of Employer Self

Amount of Each Contribution This Period

for Line Number 11a

Amount of Each Contribution This Period

Name and Address of Employer

Amount of Each Contribution This Period

Occupation Contribution Type

Name and Address of Employer

Amount of Each Contribution This Period

Occupation Contribution Type

Amount of Each Contribution This Period

Name and Address of Employer

Amount of Each Contribution This Period

Occupation Contribution Type

for Line Number 11a

Name and Address of Employer

Amount of Each Contribution This Period

Occupation Contribution Type

Amount of Each Contribution This Period

Amount of Each Contribution This Period

Amount of Each Contribution This Period

Name and Address of Employer

Amount of Each Contribution This Period

Occupation Contribution Type

for Line Number 11a

Amount of Each Contribution This Period

Name and Address of Employer Retired

Amount of Each Contribution This Period

Amount of Each Contribution This Period

Name and Address of Employer

Amount of Each Contribution This Period

Occupation Contribution Type

TOTAL This Period (Aggregate of all receipts pages)

for Line Number 15

Name and Address of Employer

Amount of Each Contribution This Period