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Oj..,T ~ Date Sig~~Ture of Treasurer KANSAS GOVERNMENTAL ETHICS COMMISSION RECEIPTS AND EXPENDITURES REPO..,.,)+-T--===-=~---, OF A POLITICAL OR PARTY COMMITTgE FILED October 29, 2012 OCT 26 2012 FILE WITH SECRETARY OF STATE KRISWKOBACH SEE REVERSE SIDE FOR INSTRUCTI01~SSECRETARY Or: STATE A. Name of Committee: Kansas Medical Society Political Action Committee Address: 6_2_3_S_W_1_0_th_A_v_e_. _ City and Zip Code: _T_o_p_e_k_a_,_K_S_6_6_6_12 _ This is a (check one): __Party Committee Political Committee B. Check only if appropriate: __Amended Filing __ Termination Report C. Summary (covering the period from July 27, 2012 through October 25,2012) 1. Cash on hand at beginning of period . $153,934.67 2. Total Contributions and Other Receipts (Use Schedule A) .. 12,842.00 3. Cash available this period (Add Lines 1 and 2) . 166,776.67 4. Total Expenditures and Other Disbursements (Use Schedule C) . 78,000.00 5. Cash on hand at close ofperiod (Subtract Line 4 from 3) . $ 88,776.67 6. In-Kind Contributions (Use Schedule B) . 7. Other Transactions (Use Schedule D) .. D. "I declare that this report, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief is true, correct and complete. I understand that the intentional failure to file this document or intentionally filing a false document is a class A misdemeanor." 10/25/12 oJ..,t ~ Date Sig~~ture of Treasurer GEe Form Rev, 2001 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Medical Society Political Action Committee Occupation & Industry of Date Name & Address Cash, Check, Loan, Amount of Cash, Check Individual Giving More of Contributor Other Loan or Other Receipt Than $150 8/14/2012 Gerald Hamilton MD Physician Check ($150.00) 23401 Prairie Star Pkwy Ste 300 Healthcare Industry Shawnee Mission, KS 66227-7246 8/14/2012 Rory Howard MD Physician Check ($132.00) 555 W 15th St Healthcare Industry Liberal, KS 67901-2467 8/14/2012 Dylan YuMD Physician Check ($150.00) 3630 SW Fairlawn Rd Healthcare Industry Topeka, KS 66614-3966 8/24/2012 KC Docs PAC KS-West Physician Group Check ($8,220.00) 3036 Gillham Rd Healthcare Industry Kansas City, MO 64108 9/11/2012 Alan Clement MD Physician Check ($150.00) 2040 Hutton Rd Ste 102 Healthcare Industry Kansas City, KS 66109-4564 9/11/2012 Mehmood Hashmi MD Physician Check ($150.00) 1414 SW 8th Ave Healthcare Industry Topeka, KS 66606-1535 9/11/2012 Jeffrey Leichter MD Physician Check ($150.00) 1133 College Ave A104 Healthcare Industry Manhattan, KS 66502-2700 9/11/2012 Joshua Thomas DO Physician Check ($150.00) 2207 Brookfield Dr Healthcare Industry Salina, KS 67402-4646 9/11/2012 Matthew Turner MD Physician Check ($150.00) 1301 W 12th Ave Ste 207 Healthcare Industry Emporia, KS 66801-1234 9/11/2012 James Appelbaum MD Physician Check ($150.00) 8919 Parallel Pkwy Ste 555 Healthcare Industry Kansas City, KS 66112-8912 9/11/2012 Mark Basham MD Physician Check ($150.00) 110 E 16th St Healthcare Industry Eureka, KS 67045-1067 9/11/2012 Tammy Bataglia MD Physician Check ($150.00) 1 Mt Carmel Way Healthcare Industry Pittsburg, KS 66762-7587 Subtotal This Page ($9,852,00) Page 1 of 4 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Medical Society Political Action Committee Occupation & Industry of Date Name & Address Cash, Check, Loan, Amount of Cash, Check Individual Giving More of Contributor Other Loan or Other Receipt Than $150 9/11/2012 Regina Carolina MD Physician Check ($150.00) 1301 N 47th St Healthcare Industry Kansas City, KS 66102-4503 9/11/2012 Trent Davis MD Physician Check ($150.00) 520 S Santa Fe Ave Ste 300 Healthcare Industry Salina, KS 67401-4190 9/11/2012 Peter DeWitt MD Physician Check ($150.00) 1101 N Main St Healthcare Industry McPherson, KS 67460-2302 9/11/2012 Sol Enriquez MD Physician Check ($150.00) 10507 W 126th Ter Healthcare Industry Shawnee Mission, KS 66213-2356 9/11/2012 John Evans MD Physician Check ($150.00) 1500 SW 10th Ave Ste 2 N Healthcare Industry Topeka, KS 66606-1301 9/11/2012 David Finkle MD Physician Check ($150.00) 9100 W 74th St Healthcare Industry Shawnee Mission, KS 66204-4004 9/11/2012 Eric Friskel MD Physician Check ($150.00) 2800 W 67th St Healthcare Industry Shawnee Mission, KS 66208-1837 9/11/2012 Brent Hrabik MD Physician Check ($150.00) 1301 W 12th St Ste 101 Healthcare Industry Emporia, KS 66801-2590 9/11/2012 Khanna Poonam MD Physician Check ($150.00) 14818 Sherwood St Healthcare Industry Shawnee Mission, KS 66224-1873 9/22/2012 Gerald Lindholm MD Physician Check ($150.00) 700 Medical Ctr Dr Ste 210 Healthcare Industry Newton, KS 67114-4446 9/11/2012 Stephen Lund MD Physician Check ($150.00) 10105 Barton St Healthcare Industry Overland Park, KS 66214-2624 9/11/2012 Stephen Lund MD Physician Check ($150.00) 10105 Barton St Healthcare Industry Overland Park, KS 66214-2624 Subtotal This Page ($1,800.00) Page 2 of 4 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Medical Society Political Action Committee Occupation & Industry of Date Name & Address Cash, Check, Loan, Amount of Cash, Check Individual Giving More of Contributor Other Than $150 Loan or Other Receipt 9/11/2012 Raymond Magee MD Physician Check ($50.00) 601 SW Corporate View Rd Healthcare Industry Topeka, KS 66615-2715 9/11/2012 Dilip Patel MD Physician Check ($40.00) 1000 Lincoln St Healthcare Industry Emporia, KS 66801-2449 9/11/2012 Lawrence Shank MD Physician Check ($150.00) 305 W 15th St Healthcare Industry Liberal, KS 67901-4659 9/11/2012 Joseph Simone MD Physician Check ($150.00) 8901 W 74th St Ste 285 Healthcare Industry Shawnee Mission, KS 66204-2287 9/11/2012 Richard Uhlig MD Physician Check ($150.00) 100 E Helen St Healthcare Industry Herington, KS 67449-1606 9/11/2012 Linda Warren Physician Check ($100.00) 205 S Hanover St Healthcare Industry Hanover, KS 66945-8924 9/11/2012 Roger Warren MD Physician Check ($100.00) 205 S Hanover St Healthcare Industry Hanover, KS 66945-8924 9/11/2012 Donald White MD Physician Check ($150.00) P.O. Box 1449 Healthcare Industry Coffeyville, KS 67337-0937 9/11/2012 James Whitten MD Physician Check ($150.00) 12909 Westgate St Healthcare Industry Shawnee Mission, KS 66213-2365 9/11/2012 Daryl Zerbe MD Physician Check ($150.00) PO Box 1607 Healthcare Industry Salina, KS 67402-1607 Subtotal This Page ($1,190.00) Page 3 of 4 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Medical Society Political Action Committee (Name ofParty Committee or Political Committee) Occupation & Industry of . Check Amount of Name and Address Individual Giving More Appropriate Box Cash, Check, Date of Contributor Than $150 Loan or Other Cash Check Loan E funds Other Receipt .... $0.00 Subtotal This Page Complete if last page of Schedule A Total Itemized Receipts for Period $12,842.00 Total Unitemized Contributions ($50 or less) Sale ofPolitical Materials (Unitemized) Total Contributions When Contributor Not Known . ,. TOTAL RECEIPTS TmS PERIOD (to line 2 of Summary) . $12,842.00 Page _4_ of_4_ SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Medical Society Political Action Committee Purpose of Expenditure Date Narne and Address List candidate name & address if independent or Amount in-kind expenditure in excess of $300 $ 08/20/12 Shanti Gandhi Campaign Contribution 500.00 5802 Clarion Lakes Way Topeka, KS 66610 10/01/12 Robert "Bob" Grant Campaign Contribution 250.00 202 S. Appleton Frontenac, KS 66763 10/01/12 Michelle Hucke Campaign Contribution 250.00 1914 South Locust Pittsburg, KS 66762 10/01/12 Bill Feuerborn Campaign Contribution 500.00 1600 Park Rd. Garnett, KS 66032 10/01/12 Jene Vickrey Campaign Contribution 500.00 502 S. Countryside Dr. Louisburg, KS 66053 10/01/12 Richard ProeW Campaign Contribution 500.00 510 Pine Ridge Rd. Parsons, KS 67357 10/01/12 Craig McPherson Campaign Contribution 250.00 11091 W. 133rd Ter. Apt. 7 Overland Park, KS 66213 10/01/12 Edwin Bideau Campaign Contribution 250.00 14 S. Rutter Chanute, KS 66720 10/01/12 Jim Kelly Campaign Contribution 500.00 309 S. 5th Independence, KS 67301 10/01/12 Virgil Peck Campaign Contribution 500.00 Box 277 Tyro, KS 67364 10/01/12 Fred Rinne Campaign Contribution 250.00 610 Madison Fredonia, KS 66736 10/01/12 Keith Esau Campaign Contribution 250.00 11702 S. Winchester St. Olathe, KS 66061 Subtotal This Page $4,500.00 Page _1 of--.H SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Medical Society Political Action Committee Purpose of Expenditure Date Narne and Address List candidate name & address if independent or Amount in-kind expenditure in excess of $300 $ 10/01/12 Robert Montgomery Campaign Contribution 250.00 107 W. Cedar Olathe, KS 66061 10/01/12 Amanda Grosserode Campaign Contribution 250.00 12601 West 99th St. Lenexa, KS 66215 10/01/12 Brett Hi1dabrand Campaign Contribution 250.00 16820 W. 67th St., Apt. 407 Shawnee, KS 66217 10/01/12 John Rubin Campaign Contribution 500.00 13803 W. 53 rd St. Shawnee,KS 66216 10/01/12 Rob Bruchman Campaign Contribution 250.00 5016 W. 108th Terr., #522 Overland Park, KS 66211 10/01/12 Barbara Bollier Campaign Contribution 500.00 691 0 Overhill Rd. Mission Hills, KS 66208 10/01/12 Marla Brems Campaign Contribution 250.00 8610 Mackey St. Overland Park, KS 66212 10/01/12 Kelly Meigs Campaign Contribution 500.00 7842 Rosehill Rd. Lenexa, KS 66216 10/01/12 Christopher Waldschmidt Campaign Contribution 250.00 7201 W. 72nd St. Overland Park, KS 66204 10/01/12 Larry Campbell Campaign Contribution 250.00 15803 S. Avalon Olathe, KS 66062 10/01/12 Ray Merrick Campaign Contribution 500.00 6874 West 164th Ter.
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