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Political Action Committee (Pac) Quarterly Reporting Form

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POLITICAL ACTION COMMITTEE (PAC) QUARTERLY REPORTING FORM For assistance in completing To be filed with: Calendar year 2015 this form contact: Mark Martin, Secretary of State Arkansas Ethics Commission State Capitol, Room 026 Post Office Box 1917 Little Rock, AR 72201 Little Rock, AR 72203 Phone (501) 682-5070 Phone (501) 324-9600 Fax (501) 682-3408 Toll Free (800) 422-7773 1. NAME OF COMMITTEE (IN FULL) 2. TYPE OF REPORT Arkansas Dental PAC First Quarter–due April 15 covers January 1 through March 31 ADDRESS Second Quarter–due July 15 5304 Mabelvale Pike covers April 1 through June 30 Third Quarter–due Oct 15 covers July 1 through September 30 Fourth Quarter–due Jan 15 covers October 1 through December 31 CITY, STATE AND ZIP CODE 3. IS THIS REPORT AN AMENDMENT? Little Rock, AR 72209 YES NO SUMMARY FOR REPORTING CUMULATIVE PERIOD TOTALS 4. BALANCE OF FUNDS AT BEGINNING OF REPORTING PERIOD $80,686.67 5. INTEREST EARNED ON COMMITTEE FUNDS (IF ANY) $59.08 $773.23 6. TOTAL MONETARY CONTRIBUTIONS RECEIVED $150.00 $203,882.00 7. TOTAL CONTRIBUTIONS MADE TO CANDIDATES/COMMITTEES $(6,750.00) $137,320.00 8. ADMINISTRATIVE EXPENSES $3,060.00 $45,014.85 9. BALANCE OF FUNDS AT CLOSE OF REPORTING PERIOD $84,585.75 10. NO ACTIVITY(check if you have not received or made any contributions during this reporting period) I certify under oath that I have examined this report and to the best of my knowledge and belief the information so disclosed is a complete, true, and accurate financial statement. on file Signature of PAC Officer State of Arkansas }ss County of Subscribed and sworn before me this day of , 20 . on file Signature of Notary Public (Legible Notary Seal) My Commission Expires: Note: If faxed, notary seal must be legible (i.e., either stamped or raised and inked) and the original must follow within ten (10) days. The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of Ark. Code Ann. § 7-6-201 through § 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 12/2013 11. ITEMIZED MONETARY CONTRIBUTIONS RECEIVED BY COMMITTEES OVER $500 Please Type or Print Use Additional Copies of this Page if Necessary Date Name Address of Employer/ Amount Of Cumulative of Contributor Contributor Place Of Business Contribution Total for Year N/A 12. TOTAL ITEMIZED MONETARY CONTRIBUTIONS $0.00 RECEIVED DURING REPORTING PERIOD 13. TOTAL UNITEMIZED MONETARY CONTRIBUTIONS $150.00 RECEIVED DURING REPORTING PERIOD 14. TOTAL MONETARY CONTRIBUTIONS RECEIVED $150.00 DURING REPORTING PERIOD (to be entered on line #6) The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of Ark. Code Ann. § 7-6-201 through § 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 12/2013 15. ITEMIZED NONMONEY CONTRIBUTIONS RECEIVED BY COMMITTEES OVER $500 Please Type or Print Use Additional Copies of this Page if Necessary Date Full Name and Address of Contributor Description of Value of Cumulative of Nonmoney Item Nonmoney Item Total From Receipt This Contributor N/A 16. TOTAL ITEMIZED NONMONEY CONTRIBUTIONS $0.00 RECEIVED DURING REPORTING PERIOD 17. TOTAL NONITEMIZED NONMONEY CONTRIBUTIONS $0.00 RECEIVED DURING REPORTING PERIOD 18. TOTAL NONMONEY CONTRIBUTIONS $0.00 RECEIVED DURING REPORTING PERIOD IMPORTANT In addition to monetary contributions, political action committees are required to report the receipt of any nonmoney ('in-kind') contributions. A political action committee receives an in-kind contribution whenever a person provides it with an item or service without charge or for a charge that is less than the fair market value of the item or service in question. The value of an in-kind contribution is the difference between the fair market value and the amount charged. The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of Ark. Code Ann. § 7-6-201 through § 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 12/2013 19. ITEMIZED MONETARY CONTRIBUTIONS MADE TO CANDIDATES AND COMMITTEES OVER $50 Please Type or Print Use Additional Copies of this Page if Necessary Date Name of Address Election for Which Amount Of Candidate/Committee of Candidate/Committee Contribution was Made Contribution To Whom Contribution Made 07/23/2015 Paul Bookout Campaign 1504 Frierson uncashed/stale check from $(1,000.00) Fund Jonesboro, AR 72401 11/9/11 07/23/2015 Wes Wagner Campaign 4409 Lochmoor Cir Uncashed/stale check from $(250.00) Fund Jonesboro, AR 72401 11/9/2011 07/23/2015 Andy Mayberry Campaign 1222 Orchard Lake Lane uncashed/stale check #2257 $(250.00) Fund Hensley, AR 72065 from 9/5/2012 07/23/2015 Charlie Collins Campaign 3225 East Piper Glen uncashed/stale check #2278 $(250.00) Fund Fayetteville, AR 72703 from 9/5/2012 07/23/2015 David Meeks Campaign PMB 301 Uncashed/stale check #2273 $(250.00) Fund 813 Oak St., Ste. 10A from 9/5/2012 Conway, AR 72032 07/23/2015 David Kizzia Campaign 124 W. 2nd uncashed/stale check #2320 $(250.00) Fund Malvern, AR 72104 from 12/20/12 07/23/2015 Tommy Wren Campaign P.O. Box 943 uncashed/stale check #2368 $(500.00) Fund Melbourne, AR 72556 from 6/23/14 07/23/2015 Nelda Speaks Campaign P.O. Box 1016 uncashed/stale check #2372 $(250.00) Fund Mountain Home, AR 72653 from 10/1/14 07/23/2015 Camille Bennett Campaign 107 W 2nd uncashed/stale check #2376 $(250.00) Fund Lonoke, AR 72086 from 10/1/14 07/23/2015 Nate Bell Campaign Fund 419 Polk 47 uncashed/stale check #2383 $(500.00) Mena, AR 71953 from 10/1/14 07/23/2015 Brent Talley Campaign Post Office Box 256 uncashed/stale check #2393 $(250.00) Fund Hope, AR 71802 from 10/1/14 The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of Ark. Code Ann. § 7-6-201 through § 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 12/2013 07/23/2015 Charles Armstrong 9900 West 36th St uncashed/stale check #2394 $(250.00) Campaign Fund Little Rock, AR 72204 from 10/1/14 07/23/2015 John Adams Campaign 33 Longea Dr. Uncashed/stale check #2396 $(250.00) Fund Little Rock, AR 72212 from 10/1/14 07/23/2015 Clarke Tucker Campaign P.O. Box 7268 Uncashed/stale check #2399 $(250.00) Fund Little Rock, AR 72217 from 10/1/14 07/23/2015 Charles Blake Campaign 2100 Broadway, Ste 201 Uncashed/stale check #2400 $(250.00) Fund Little Rock, AR 72206 from 10/1/14 07/23/2015 Eddie Armstrong Campaign P.O. Box 5323 Uncashed/stale check # 2370 $(500.00) Fund North Little Rock, AR 72119 from 10/1/14 07/23/2015 Bob Johnson Campaign 511 N. First Street #8 Uncashed/stale check # 2717 $(250.00) Fund Jacksonville, AR 72076 from 10/1/14 07/23/2015 Joe Farrer Campaign Fund 5315 Lewisburg Road Uncashed/stale check #2717 $(250.00) Austin , AR 72007 from 10/1/14 07/23/2015 David Fielding Campaign 909 S. Vine Uncashed/stale check #2725 $(250.00) Fund Magnolia, AR, AR 71753 from 10/1/14 07/23/2015 Matthew Shepherd P.O. Box 12004 Uncashed/stale check #2737 $(500.00) Campaign Fund El Dorado, AR 71730 07/23/2015 Tommy Wren Campaign P.O. Box 943 Uncashed/stale check #2740 $(500.00) Fund Melbourne, AR 72556 from 10/1/14 07/23/2015 Justin Harris Campaign 145 N. Pleasant St. Uncashed/stale check #3013 $(250.00) Fund West Fork, AR 72774 from 10/8/2014 07/23/2015 David Whitaker Campaign 727 N. Lewis Avenue Uncashed/stale check #3017 $(250.00) Fund Fayetteville, AR 72701 from 10/8/14 07/23/2015 Greg Leding Campaign 50 South School Ave #1 Uncashed/stale check #3018 $(500.00) Fund Fayetteville, AR 72701 from 10/8/2014 The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of Ark. Code Ann. § 7-6-201 through § 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 12/2013 07/23/2015 Lance Eads Campaign 5943 Doris Hunt Ct Uncashed/stale check #3020 $(250.00) Fund Springdale, AR 72762 from 10/8/2014 07/23/2015 Grant Hodges Campaign P.O. Box 2607 Uncashed/stale check # 3029 $(250.00) Fund Rogers, AR 72757 07/23/2015 Kelley Linck Campaign 13822 Highway 14 S Uncashed/stale check #3032 $(750.00) Fund Yellville, AR 72687 from 10/8/2014 07/23/2015 David Sanders Campaign 132 Congressional Drive Uncashed/stale check#3035 $(1,000.00) Fund Little Rock, AR 72210 from 10/8/2014 07/23/2015 Scott Flippo Campaign P.O. Box 705 Uncashed/stale check #3036 $(500.00) Fund Bull Shoals, AR 72619 from 10/8/2014 07/23/2015 Jeremy Hutchinson #3 Chenal Wood Drive, #331 Uncashed/stale check #3043 $(1,000.00) Campaign Fund Little Rock, AR 72223 from 10/8/2014 07/23/2015 John Catlett Campaign 11732 W.
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