__Ul/U!J / 2015 15: 31! FAX Kansas Hospital Assoc 141001
KANSAS GOVERNMENTAL ETHICS COMMISSION ff~c RECEIPTS AND EXPENDITURES REPORT ~f!l'l2Q . OF A POLITICAL OR PARTY COMMlf8 ,. EE JA,fV o 0 ,, ~'n177.~h··1 <015 October 27, 2014 ' · _;,;:..t~ 1 • " G6 Co1r;, FILE WITH SECRETARY OF STATE rniss1011 SEE REVERSE SIDE FOR INSTRUCTIONS
A. Name of Committee: Kansas Hospital AssociaUon Political Action Committee
Address: 215 SE 8th Street
City and Zip Code: r_ap_e_ka_, _ss_s_o1______
This is a (check one): __ Party Committee X Political Committee
B. Check only if appropriate: L Amended Filing __ Termination Report
C. Summary {covering the period from July 2~, 2014 through October 23, 2014) $93,891.25 1. Cash on hand at beginning of period ...... 2. Total Contributions and Other Receipts (Use Schedule A) ...... $35,921.30 3. Cash available this period (Add Lines 1 and 2) ...... $129,812.55 4. Total Expenditures and Other Disbursements (Use Schedule C) ...... $56,073.51 5. Cash on hand at close of period (Subtract Line 4 from 3) ...... $73,739.04 6. In-Kind Contributions (Use Schedule B) ...... $2,469.84 7. Other Transactions (Use Schedule D) ...... $0.00
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 belie is true, correct and com lete. I understand that the intentional failure to file this document or· entiona filing a · lass A mis errieanor."
Date
GEC Form Rev, 2014 Ul / UlJ / ZUlb 1!:>:;51! J:<"AA Kansas Hospital Assoc 141002
SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS
Kansas Hospital Association Political Action Committee (Name of Party 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 ~ Receipt
Randall Brown Chief of Medical Staff $100.00 117211th Rd Community Memorial Healthcare 07/30/2014 Marysville, KS 66508-8643 ./
Curtis Hawkinson Chief Executive Officer $280.00 1109 Keystone Rd. Community Memorial Healthcare 07/3012014 Marysville, KS 66508-1338 ./
Chad Austin Sr. Vice President, Government $76.92 6518 SW 26th Court Relations 07/30/2014 Topeka, KS 66614-4305 Kansas Hospital Association ./
Kevan Trenkle Chief Executive Officer $100.00 1473 Prairie Dr. Citizens Medical Center 08/08/2014 Colby, KS 67701-9303
Steven Perkins Chief Executive Officer $350.00 20 Crestwood Dr. South Central Kansas Medical 08/12/2014 Arkansas City, KS 67005-9005 Center
Service Corporation Kansas Health $1,000.00 Kansas Hospital Association 08115/2014
Harold Courtois Chief Executive Officer $200.00 08/15/2014 PO Box 851 Russell Regional Hospital Russell, KS 67665-0851
Rosalind Lewis Chief Nursing Officer $200.00 08119/2014 13477 Curtiss Circle Commun,lty HealthCare System Onaga, KS 66521-9574
George Stover Chief Executive Officer $325.00 08/22/2014 1227 W. Noble St. Rice County District Hospital Lyons, KS 67554-3029
Steve Elmore $425.00 08/22/2014 1107 McArtar Rd. United Wireless Dodge City, KS 67801-6031
Trustee • $4,700.00 08122/2014
$7,756.92
Page _1__ of_1_1_ UL / Ul:l / ZULn Ln:il1S !''AA. Kansas Hospital Assoc !41003
SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS
Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee)
Occupation & Industry of Check Amount of Name and Address Individual Giving More Appr9prfate Box Cash, Check, Date of Contributor Than $150 Loan or Other Cash Check Loan E funds 0th.;"" Receipt
Joni Bergstrom OR Supervisor $150.00 Cloud County Health Center 08/22/2014 ./
John Hart Chief Executive Officer $150.00 309 N. 9th Sl Fredonia Regional Hospital 08/22/2014 Fredonia, KS 66736-1421 ./
Tracy Fanshier Trustee-Stafford Co. Hosp. $3,100.00 2010 N. US Hwy 281 08/22/2014 Great Bend, KS 67530-8712 ./
Joe Pedley Vice President and Chief Financial $100.00 5624 Villa Drive Officer 08/27/2014 Lawrence, KS 66047-8300 Lawrence Memorial Hospital ./
Kathleen Clausing-Willis Vice President/COO $100.00 1071 E 1400 Rd Lawrence Memorial Hospital 08/27/2014 Lawrence, KS 66046-9633 ./
Jane Maskus Vice President and Chief 5100.00 24215 W. 68th St. Information Officer 08/27/2014 Shawnee, KS 66226-3539 Lawrence Memorial Hospital ./
Eugene Meyer President and Chief Executive $500.00 08/27/2014 325 Maine Street Officer Lawrence, KS 66044-1360 Lawrence Memorial Hospital ./
Janice Early Hospital Employee $100.00 08/27/2014 902 Riverside Ct Lawrence Memorial Hospital Lawrence, KS 66044-4092 ./
Sheryle D'Amico VP $200,00 08/27/2014 737 N. 1550 Rd. Lawrence Memorial Hospital Lawrence, KS 66049-9198 ./
Joe Duerr Chief Executive Officer $250.00 08/29/2014 501 North 14th Street Morton County Health System Perry, OK 73077-5021 ./
Chief Executive Officer $200.00 08/29/2014 Rawlins County Health Center ./
$4,QSO.OO
Page _2__ of-22._ 01/ 09 / 2015 15:39 FAX Kansas Hospital Assoc 141004
SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS
Kansas Hospital Association Political Action Committee (Name of Party 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 ~ Other Receipt
Terry Pound Chief Financial Officer $150.00 420 S Pioneer Rice County District Hospital 08/29/2014 Lyons, KS 67554-2613 ./
George Stover Chief Executive Officer 5150.00 1227 W. Noble St. Rice County District Hospital 08/29/2014 Lyons, KS 67554-3029 ./
Randy Lindauer Chief Executive Officer $200.00 Coffey County Hospital 08/29/2014 ./
Tammy Peterman Executive Vice President, Chief $500.00 3901 Rainbow Blvd Operating Officer 08/29/2014 Kansas City, KS 66103-2937 - University of Kansas Hospital, The
Kevin Hicks President end CEO $1 ,000.00 2316 East Meyer Boulevard Overland Park Regional Medical 09/04/2014 Kansas City, MO 64132-1136 Center
Steven Wilkinson President and Chief Executive $1,500.00 5721 West 119th Street Officer 09/04/2014 Overland Park, KS 66209-3722 Menorah Medical Center ./
Hugh Tappan President and Chief Executive $2,500.00 09/0412014 14000 E. Castlewood Circle Officer Wichita, KS 67214-4910 Wesley Medical Center ./
Dennis Hachenberg Chief Executive Officer $500.00 09/04/2014 105 N. Oak St. Anderso~ County Hospital Garnett, KS 66032-0309 ./
Adele Ducharme Chief Executive Officer $500.00 09/04/2014 2218 NW 81st Ct Saint Luke's Cushing Hospital Kansas City, MO 64151-3700 ./
Jani Johnson President and Chief Executive $600.00 09/04/2014 7416 Mullen Rd Officer Shawnee, KS 66216-3777 Saint Luke's South Hospital ./
Sr. Vice President, Government $76.92 09/04/2014 Relations Kansas Hospital Association ./
{It~'"-, $7,676.92
Page _3__ of_1_1_ 01/ 09/ 2015 15:39 FAX Kansas Hospita~ Assoc 14!005
SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS
Kansas Hospital Association Political Aclion Committee (Name of Party 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 Loso E fuods ~ Receipt
Julie Ward Vice President of Patient Care $100.00 3215 Northwestern Avenue Services 09/05/2014 Hutchinson, KS 67502-1105 Hutchinson Regional Medical Center ./
Kevin Miller President and Chief Executive $100.00 69 Willowbrook Rd. Officer 09/05/2014 Hutchinson, KS 67502-8006 Hutchinson Regional Medical Center ./
Kendall E. Johnson $100.00 4403 Spyglass Hutchinson Regional Medical 09/05/2014 Hutchinson, KS 67502-5643 Center ./
Peggy R. Tuxhorn $100.00 2503 Rambler Rd. Hutchinson Regional Medical 09/05/2014 Hutchinson, KS 67502-5133 Center . ./
Jenice Schulte OR Manager $100.00 3811 Mission Dr. Hutchinson Regional Medical 09/05/2014 Hutchinson, KS 67502-8096 Center ./
Jeremy Taylor Director of Imaging $100.00 900 E. 36th Hutchinson Regional Medical 09/05/2014 Hutchinson, KS 67502-3001 Center ./
Elizabeth Peirce Board Mli'mber $100.00 09/05/2014 2813 Westminster Dr. Hutchinson Regional Medical Hutchinson, KS 67502-2552 · Center ./
Cassie Dolen CFO $200.00 09/05/2014 404 N. Fern Circle Hutchinson Regional Medical Sedgwick, KS 67135-3505 Center ./
William Giersch $100.00 09/05/2014 5713 N. Lorriane Hutchinson Regional Medical Hutchinson, KS 67502-8750 Center ./
Kevin Chiles VP Human Resources $100.00 09/05/2014 1200 N. Autumn Drive Hutchinson Regional Medical Goddard, KS 67052-8444 Center ./
ichard Miller Administrator and Chief Executive $250.00 09/05/2014 10 Valley Vista Officer orion, KS 67654-0250 Norton County Hospital ./
$1.350.00
Page _4__ of-22._ U.L / Ul:l / ZU.Lt> .Lt>:3l:I l SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Occupation & Industry of Check Amount of Name and Address Individual Giving More Appropriate Box Cash, Check, Date of Contributor Than SlSO Loan or Other Ca1h Check Loan !l!!.ru!! Olher .Receipt Bob Page Chief Executive Officer $1,000.00 13413 W. 75th Ct. University of Kansas Hospital, The 09/05/2014 Shawnee, KS 66216-3078 ./ John Hart Chief Executive Officer S125.00 309 N. 9th SI. Fredonia Regional Hospital 09/05/2014 Fredonia, KS 66736-1421 ./ Lee Norman Chief Medical Officer $500.00 210 W 5th St University of Kansas Hospital, The 09/07/2014 #205 Kansas City, MO 64105-1166 Karen Shumate Chief Operating Officer $100.00 1753 E 980 Rd Lawrence Memorial Hospital 09/12/2014 Lawrence, KS 66049-9073 Bryan Coffey Chief Executive Officer $150.00 PO Box 1302 Hamilton County Hospital 09/16/2014 Syracuse, KS 67878-1302 Robin Coffey MD $150.00 PO Box 1302 Hamilton County Hospital 09/16/2014 Syracuse, KS 67878-1302 .t/ Matthew Bible Manager $100.00 09/17/2014 3901 W. 12th St. St. Francis Health Center Lawrence, KS 66049-3507 ./ Mary Clare Wilson Director $100.00 09/17/2014 4624 SE Oak Bend Dr. St. Francis Health Center Barryton, KS 66409-9227 ./ Marshall Meek Executive Director - Foundation $100.00 09/17/2014 6103 SW 30th Terr. St. Francis Health Center Topeka, KS 66610-1307 ./ Sharon McCaleb Director Muscularskeletal Service $100.00 09/18/2014 16836 NE 94th Rd. SI. Francis Health Center Topeka, KS 66617-3216 ./ Director ER Occ Health $100.00 09/18/2014 St. Francis Health Center t/ $2,525.00 Page _5__ of_1_1_ u 1 1 u ~ / z u 1 n 1 n : 4 u !<'AA Kansas Hospital Assoc 141007 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Actlon Committee (Name of Party 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 Efunds oo;,:- Receipt Scott Wells CNO $100.00 6324 SW 48th Lane St. Francis Health Center 09/18/2014 Topeka, KS 66610-1609 ~ Paula Ellis Director · $100.00 9199 K4 Hwy St. Francis Health Center 09/18/2014 Meriden, KS 66512-8851 ./ David Satchel Chief Operating Officer $100.00 2601 SW Berkshire Drive St. Francis Health Center 09/18/2014 Topeka, KS 66614-4675 ~ Helen Williams Director $100.00 2234 NW 78th St. Francis Health Center 09/18/2014 Topeka, KS 66618-2111 ./ Robert Erickson President and Chief Executive $350.00 3609 Randolph Ave. Officer 09/18/2014 Topeka, KS 66611-1728 St. Francis Health Center ./ Carol Gitto Director, Physician Clinical $100.00 3749 SW Stonybrook Drive Operations 09/18/2014 Topeka, KS 66610-1306 St. Francis Health Center ./ Eric Barnaby Vice President Strategic & $75.00 09/18/2014 338 SW Woodlawn Ave BusinesS' Dev. Topeka, KS 66606-1245 St. Francis Health Center ~ Sherri Vaughn MD $100.00 09/18/2014 1216 Waverly Dr. Lawrence Memorial Hospital Lawrence, KS 66049-5016 ./ John Jacobson Chief Executive Officer $300,00 09/1812014 3955 Hwy73 Atchison Hospital Atchison, KS 66002-9204 ~ Dennis Shelby Chief Executive Officer $100.00 09/18/2014 P 0 Box 727 Wilson Medical Center Alva, OK 73717-0727 ohn Moore Administrator $100.00 09/19/2014 1402 260th SL Hiawatha Community Hospital iawatha, KS 66434-8102 ./ $1,525.00 Page _6__ of_1_1_ . I r' Ul / U~ / 2Ul5 15:4U FAX Kansas Hospital Assoc 141008 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party 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 Ott;;;"" Receipt Jon Jackson Sr. VP, Chief Administrative $500.00 8000 Tomahawk Road Officer 09/19/2014 Prairie Village, KS 66208-4845 University of Kansas Hospital, The ./ Chris Hansen Senior Vice President Ambulatory $500.00 5710 W 12Bth Street Services and Chia 09/19/2014 Overland Park, KS 66209-3681 University of Kansas Hospital, The ./ Bill Marting Senior Vice President and Chief $500.00 2608 NW Thoreau Dr. Financial Officer 09/19/2014 Lees Summit, MO 64081-2265 University of Kansas Hospital, The ./ Paul Davis interim CEO $100.00 KS Sheridan County Health Complex 09/19/2014 ./ Chad Austin Sr. Vice President, Government $76.92 6518 SW 26th Court Relations 09/19/2014 Topeka, KS 66614-4305 Kansas Hospital Association Melissa Hungerford Sr. Vice President $19.24 6448 SW Bayshore Dr Kansas Hospital Association 09/19/2014 Auburn, KS 66402-9324 Cindy Samuelson Vice President $19.24 09/19/2014 1107 NE 54th St Kansas Hospital Association Topeka, KS 66617-4505 ./ Rick Kellerman Professor and Chair $100.00 09/19/2014 521 N. Armour Sl University of Kansas Hospital, The Wichita, KS 67206-1513 ./ John Moore Administrator $250.00 09/23/2014 1402 260th St. Hiawatha Community Hospital Hiawatha, KS 66434-8102 I Greg Unruh Chief Executive Officer $350.00 09/23/2014 700 Leonard Community HealthCare System Onaga, KS 66521-9574 ./ $400.00 09/23/2014 Conrade Insurance Group ./ $2,615.40 Page _7__ of_1_1_ Ul / Ul:! / ZU15 15:40 FAX Kansas Hospital Assoc !41009 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Occupation & lndustry 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 Cindy Samuelsori Vice President $1.00 1107 NE 54th St Kansas Hospital Association 09/23/2014 Topeka, KS 66617-4505 ./ Cindy Samuelson Vice Pre1?idenl $1 .00 1107 NE 54th St Kansas Hospital Association 09/23/2014 Topeka, KS 66617-4505 ./ Kiley Floyd Administrator $200.00 224 N. 4th Osborne County Memorial 09/24/2014 Osborne, KS 67473-0070 Hospital ./ Eldon Koepke Chief Financial Officer $100.00 1898 290 Rd Mitchell County Hospital Health 09/26/2014 Beloit, KS 67420-0399 Systems Jeremy Armstrong Chief Executive Officer $100.00 535 South Freeborn Mitchell County Hospital Health 09/26/2014 Marion, KS 66861-1256 Systems ./ LLP BKD CPA & Consulting Services 5250.00 125 North Market Street BKD, LLP 09/26/2014 Suite 1300 Wichita, ks 67202-1713 William Widener Administrator and Chief Executive $250.00 09/30/2014 P 0 Box 399 Officer Kremmling, CO 80459-0399 Harper Hospital District Five Karma Huck Chief Operating Officer $100.00 10/03/2014 107 Westivew Scott County Hospital Scott City, KS 67871-1352 ./ Bruce Witt Director, Government Relations $100.00 10/07/2014 820 Carriage Rd. Via Christi Health Maize, KS 67101-9697 ./ Steven Poage Vice President/CFO $350.00 10/08/2014 3401 SW Alameda Kansas Hospital Association Topeka, KS 66614-5109 ./ eborah Stem Clinical Services/legal Counsel $100.00 10/08/2014 338 SW Alameda Dr. Kansas Hospital Association opeka, KS 66604-2660 ./ $1 ,552.00 Page _8__ of_1_1_ Ul / U!J / ZU15 15:41 FAX Kansas Hospital Assoc ~010 SCHEDULE A CONTRIBUTION~ AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Occupation & Industry of Check Amount of Name and Address Individual Giving More Appro~riate Box Cash, Check, Date of Contributor Than $150 Loan or Other Cash Check Loan E funds Other Receipt Michael Thomas Administrator $380.00 PO Box 939 Meade District Hospital 10/08/2014 Meade, KS 67864-0820 ./ Stephanie Saucedo Business Office Manager $75.00 PO Box755 Meade District Hospital 10/08/2014 Meade, KS 67864-0755 ./ Ron Bender Chief Executive Officer $100.00 POBox512 Clay Cou,nty Medical Center 10/08/2014 Clay Center, KS 67432-0512 ./ Shannan Flach · Chief Execulive Officer $160.00 RR1 Box415 Wamego Health Center 10/08/2014 Paxico, KS 66526 John Moore Administrator $50.00 1402 260th St. Hiawatha Community Hospital 10/08/2014 Hiawatha, KS 66434-8102 ./ Linda Miller Director of Social Services $100.00 421 N. Sherman Ave. Apt. 2 Southwest Medical Center 10/08/2014 Liberal, KS 67901-3259 ./ Letitia Hollingsworth Director of Reimbursement $200.00 10/08/2014 2635 SW Santa Fe Dr. Kansas Hospital Association Topeka, KS 66614-4956 ./ Coleen Tummons $200.00 10/08/2014 200 Castle Rock Street Gove County Medical Center Quinter, KS 67752-9777 ./ Frank Rajewski CFO $100.00 10/08/2014 P 0 Box 389 Rooks County Health Center Plainville, KS 67663-0389 ./ Mike Sinclair CEO $100.00 10/08/2014 P 0 Box 389 Rooks County Health Center Plainville, KS 67663-0389 ./ elly McDermeit Director Outreach and Support $75.00 10/08/2014 10390 SW Lakeview Drive Services' ratt, KS 67124-8209 Prati Regional Medical Center ./ $1,540.00 Page _9__ of_1_1_ Ul / U~ / ZUlb 15:41 ¥AX Kansas Hospital Assoc 141011 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Occupation & Industry of Check Amount of Name and Address Individual Giving More Appropriate Box Cash, Check, Date of Contributor Than SlSO Loan or Other Cash Check Loon E funds ~ Receipt Vincent Wilczek $100,00 PO Box 8603 Pratt Regional Medical Center 10/08/2014 Pratt, KS 67124-8603 ./ Susan Page President and Chief Executive $200.00 1410 Maple St. Officer 10/08/2014 Pratt, KS 67124-2903 Pratt Regional Medical Center ./ Jeremy Armstrong Chief Executive Officer $137.00 535 South Freeborn Mitchell County Hospital Health 10/08/2014 Marion, KS 66861-1256 Systems ./ $437.00 Page _1_0_ of_1_1_ Ul / U9 / ZU15 15:41 FAX Kansas Hospital Assoc (4J 012 SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party 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 OH;;;- Receipt Claudio Ferraro VP Planning $100.00 541 N. Tallyrand St. Via Christi Regional Medical 10/08/2014 Wichita, KS 67206-1112 Center-St. Joseph Cam ./ Richard Kraemer VP $500.00 1007 W36 10111/2014 Hays Medical Center Hays, KS 67601-1505 Robert Mullen Retired $100.00 1704 Sheffield Circle Rice County District hlospital 10/17/2014 Manhattan, KS 66503-2220 ./ Kathi McKinney CNO/Risk $100.00 216 E 5th 10/17/2014 Labette Health Erie, KS 66733-1604 ./ Christina Sykes Director Human Resources $75.00 1902 South U S Highway 59 Labette Health 10/17/2014 Parsons, KS 67357-4948 ./ Thomas Macaronas Chief Financial Officer $100.00 701West6th Labette Health 10/1712014 Coffeyville, KS 67337-4021 \ ./ Genette Nicholas Vice President Director $250.00 10/17/2014 1001 West 58th Street Government Relations Kansas City, MO 64113-1232 Children's Mercy Hospitals and ./ Clinic~ Jeffrey Korsmo President and Chief Executive $1,000.00 10/1712014 2026 Telemark Ct NW Officer Rochester, MN 55901-2432 Via Christi Health ./ $2,225.00 Complete if last page of Schedule A Total Itemized Receipts for Period $34,353.24 Total Unitemized Contributions ($50 or less) $1,568.06 Sale of Political Materials (Unitemized) $0.00 $0.00 $35,921.30 Page _1_1 _ of_1_1_ 01/ 09/ 2015 15:42 FAX Kansas Hospital Assoc 14! 013 SCHEDULED IN-KIND CONTRIBUTIONS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) List Occupation & VaJue of Date Name and Address Industry for Those Giving Description of In-Kind In-Kind of Contributor an In-Kind of More Than Contribution Contribution SlSO Kansas Hospital Association Quik Print - KHA-PAC 07/25/2014 215 SE Eighth card/envelope $215.97 Topeka, KS 66603 Kansas Hospital Association Staff Travel AHA PAC Retreat 07/31/2014 215 SE Eighth $720.53 Topeka, KS 66603 Kansas Hospital Association KHA-PAC Auction Items 215 SE Eighth 07/31/2014 $659.61 Topeka, KS 66603 Kansas Hospital Association Deluxe - Check re-order 215 SE Eighth $214.12 09/16/2014 Topeka, KS 66603 Kansas Hospital Association Printing - Sign for KHA-PAC Event 215 SE Eighth 09/25/2014 Topeka, KS 66603 $659.61 $2,469.84 Complete if last page of Schedule B Total Itemized (over$ I 00) In-Kind Contributions $2,469.84 Total Unitemized (SlOO or less) In-Kind Contri~utions $0.00 $2,469.84 Page _1__ of_1__ 01 / 09/ 2015 15:42 FAX Kansas Hospital Assoc @] 014 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) PurJ!OSe of ExEenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address AHAPAC-American Hospital Association KHA to AHA PAC Transfer FEDERAL $259.55 07/30/2014 800 10th Street, NW Two City Center, Suite 400 Square Up Tom Willis 8/22/14 08/22/2014 $129.25 Square Up Joni Bergstrom 8/22/14 08/22/2014 $4.13 Square Up John Hart 8/22/14 08/22/2014 $4.13 Square Up Tracy Fanshier 8/22/14 08/22/2014 $85.25 BlueTree Marketing Corp. Consignment Items Invoice #2707 3500 Mystic Pointe Drive 08/29/2014 $7,205.00 Suite 504 Aventura, FL 33180 Square Up Tammy Peterman 8/29/14 08/29/2014 $13.75 Square Up Julie Ward 9/5/14 09/05/2014 $2.75 Square Up Julie Quanstrom 9/5/14 09/05/2014 $0.69 Square Up Jeffrey Paulsen 9/5/14 09/05/2014 $0.55 $7,705.05 Page_1_of~ Ul / U8 / 2Ul5 15:42 FAX Kansas Hospital Assoc 141015 I SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) PurEose of ExEenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address Square Up Lee Norman 09/07/14 $13.75 09/07/2014 Larry Hibbard for Kansas House Larry Hibbard, STATE HOUSE 13th KS 858 EE 75 Rd. 09/08/2014 Toronto, KS 66777 $250.00 Ray Merrick for Kansas House Ray Merrick, STATE HOUSE 27th KS 6874 West 164th Terr $500.00 09/08/2014 Stilwell, KS 66085 Kathy Wolfe Moore for Kansas House Kathy Moore, STATE HOUSE 36th KS 3209 N 131st Street $500.00 09/08/2014 Kansas City, KS 66109 Marvin Kleeb for Kansas House Marvin Kleeb, STATE HOUSE 48th KS 14206 Eby $500.00 09/08/2014 Overland Park, KS 66221 Scott Schwab for Kansas House Scott Schwab, STATE HOUSE 49th KS 14953 W 140th Terr 09/08/2014 $500.00 Olathe, KS 66062 Sydney Carlin for Kansas House Sydney Carlin, STATE HOUSE 66!h KS 09/08/2014 1650 sunnyslope $250.00 Manhattan, KS 66502 Tom Phillips for Kansas House Tom Phillips, STATE HOUSE 67th KS 09/08/2014 PO Box 1731 $500 .00 Manhattan, KS 66505-1732 Tom Moxley for Kansas House Tom Moxley, STATE HOUSE 681h KS 09/08/2014 1852 S 200 Road $500.00 Council Grove, KS 66846 Marc Rhoades for Kansas House Marc Rhoades, STATE HOUSE 72nd KS 09/08/2014 100 Duncan Terrace $500.00 Newton, KS 67114 $4,013.75 Page_2_of~ 01 / 09 / 2015 15:43 FAX Kansas Hospital Assoc 141016 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Pureose of Exeenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate,.list candidate name & address Daniel R. Hawkins for Kansas House Daniel Hawkins, STATE HOUSE 10oth KS 9406 Harvest Ln. $500.00 09/06/2014 Wichita, KS 67212 Steven Becker for Kansas House Steven Becker, STATE HOUSE 104th KS PO Box 384 09/08/2014 Buhler, KS 67522 $500.00 John Edmonds for Kansas House John Edmonds, STATE HOUSE 112th KS 1607 Tyler 09/08/2014 P.O. Box 1616 $500.00 Great Bend, KS 67530 Bud Estes for Kansas House Bud Estes, STATE HOUSE 119th KS 1405 Elbow Bend $500.00 09/06/2014 Dodge City, KS 67801 Tom Hawk for Kansas Senate Tom Hawk, STATE SENATE 22nd KS 2600 Woodhaven Ct. $500.00 09/08/2014 Manhattan, KS 66502 Marty Read for Kansas House Marty Read, STATE HOUSE 4th KS 16244 KS Hwy 52 09/08/2014 $250.00 Mound City, KS 66056 Kent Thompson for Kansas House Kent Thompson, STATE HOUSE 9th KS PO 8ox626 09/06/2014 $500.00 Iola, KS 66749 Barbara W. Ballard for Kansas House Barbara W. Ballard, STATE HOUSE 44th KS 1532 Alvamar Drive 09/06/2014 $250.00 Lawrence, KS 66047 Tom Sloan for Kansas House Tom Sloan, STATE HOUSE 45th KS 09/08/2014 772 Highway 40 $250.00 Lawrence, KS 66049 Jerry Henry for Kansas House Gerald Henry, STATE HOUSE 63rd KS 09/08/2014 3515 Neosho Road Cummings, KS 66016 $250.00 $4,000.00 Page_3_of~ 01 / 09 / 2015 15:43 FAX Kansas Hospital Assoc 141017 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Polttical Action Committee (Name of Party Committee or Political Committee) Pu!]!ose of ExEenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address Susie Swanson for Kansas House Susie Swanson, STATE HOUSE 64th KS 1422 5th $500.00 09/08/2014 Clay Center, KS 67432 Marci Francisco for Kansas Senate Marci Francisco, STATE SENATE 2nd KS 1101 Ohio 09/08/2014 Lawrence, KS 66044 $250.00 Richard Proehl for Kansas House Richard Proehl, STATE HOUSE 7th KS 510 Pine Ridge Rd 09/09/2014 Parsons, KS 67357 $250.00 Nancy Bauder for State Representative Nancy Bauder, STATE HOUSE 41st KS 721 S 21st St $250.00 09/09/2014 Leavenworth, KS 66048 Steven Brunk for Kansas State House Steven Brunk, STATE HOUSE 85th KS 8119 E Champions Ct 09/09/2014 Wichila, KS 67226 $250.00 Jim Ward for Kansas State House Jim Ward, STATE HOUSE 86th KS 3100 E Clark 09/09/2014 $250.00 Wichita, KS 67211 Gene Suellentrop for Kansas House Gene Suellentrop, STATE HOUSE 91sl KS 6813 W. Northwind Circle 09/09/2014 $500.00 Wichita, KS 67205 Brandon Whipple for Kansas House Brandon Whipple, STATE HOUSE 96th KS 09/09/2014 2925 S. Walnut $250.00 Wichita, KS 67217 Jeff King for Kansas Senate Jeff King, STATE SENATE 15th KS 09/09/2014 1212 North 2nd Street $350.00 Independence, KS 67301 Michael O'Donnell for Kansas Senate Michael O'Donnell, STATE SENATE 25th KS 09/09/2014 1435 W. Haskell Wichita, KS 67213 $500.00 $3,350.00 Page_4_of~ 01/ 09/ 2015 15:43 FAX Kansas Hospital Assoc 141018 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Purl!ose of Exeenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in~kind expenditure in excess of $300 is made for a candidate, list candidate name & address Leslie D. Donovan for Kansas Senate Leslie Donovan, STATE SENATE 27th KS 314 N. Rainbow Lake $500.00 09/09/2014 Wichita, KS 67235 AHAPAC-American Hospital Association KHA to AHA PAC Transfer FEDERAL 09/10/2014 800 10th Street, NW $2,422.05 Two City Center, Suite 400 Jene Vickrey for Slate House Jene Vickrey, STATE HOUSE 6th KS 502 S. Countryside $500.00 09/10/2014 Louisburg, KS 66053 Jim Kelly for Kansas House Jim Kelly; STA TE HOUSE 12th KS 309 5th s. $500.00 09/10/2014 Independence, KS 67301 Erin Davis for State House Erin Davis, STATE HOUSE 15th KS 12018 S. Clinton $250.00 09/10/2014 Olathe, KS 66061 Barbara Bollier for Kansas House Barbara Bollier, STATE HOUSE 21st KS 6910 Overhlll Road 09/10/2014 $250.00 Mission Hills, KS 66208 Nancy Lusk for Kansas House Nancy Lusk, STATE HOUSE 22nd KS 09/10/2014 PO Box 35 $250.00 Overland Park, Melissa Rooker for State Representative Melissa Rooker, STATE HOUSE 25th KS 09/10/2014 4124 Brookridge Drive $500.00 Fairway, KS 66205 Larry Campbell for Kansas House Larry CaF)1pbell , STATE HOUSE 26th KS 15803 S. Avalon 09/10/2014 $500.00 Olathe, KS 66062 Ramon Gonzalez for Kansas House Ramon Gonzalez, STATE HOUSE 47th KS 09/10/2014 PO Box 12 $500.00 Perry, KS 66073 $6 , 172.05 Page_5_of~ 01/ 09/ 2015 15:44 FAX Kansas Hospital Assoc f4J 019 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Pur(!OSe of ExEenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is · made for a candidate, list candidate name & address Annie Tietze for Kansas House Annie Tietze, STATE HOUSE 53rd KS 329 SW Yorkshire Road $250.00 09/10/2014 Topeka, KS 66606 Blaine Finch for Kansas House Blaine Finch, STATE HOUSE 59th KS 5 SW Fairview Dr. 09/10/2014 Ottawa, KS 66067 $500.00 Don Hill for Kansas House Don Hill, STATE HOUSE 60th KS 1720 Luther $250.00 09/10/2014 Emporia, KS 66801 JR Claeys for Kansas House J.R. Claeys, STATE HOUSE 69th KS PO Box 501 $500.00 09/10/2014 Salina, KS 67402 John Barker for Kansas House John Barker, STATE HOUSE 70th KS 103 Wassinger Ave $500.00 09/10/2014 · Abilene, KS 67410 Diana Dierks for Kansas House Diana Dierks, STATE HOUSE 71st KS 1221 Sunrise Dr. 09/10/2014 $500.00 Salina, KS 67401 Don Schroeder for Kansas House Don Schroeder, STATE HOUSE 74lh KS 09/10/2014 13114th Ave. $250 .00 Inman, KS 67546 Ron Ryckman for Kansas House Ron Ryckman, STATE HOUSE 78th KS 09/10/2014 14234 W 158th St. $500.00 Olathe, KS 66062 Leslie Osterman for Kansas House Leslie Osterman, STATE HOUSE 97th KS 09/11/2014 1401 West Dallas $500.00 Wichita, KS 67217 Mark E. Hutton for Kansas House Marl<. Hutton, STATE HOUSE 105th KS 09/11/2014 7118 W. Clearmeadow Ct. $500.00 Wichita, KS 67205 $4,250.00 Page_6_of~ 01 / 09/ 2015 15:44 FAX Kansas Hospital Assoc !41020 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Pureose of ExEenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address Sharon Schwartz for Kansas House Sharon Schwartz, STATE HOUSE 106th KS 2051 2oth Road $500.00 09/11(2014 Washington, KS 66968 Susan L. Concannon for Kansas House Susan Concannon, STATE HOUSE 107th KS 921 North Mill 09/11(2014 Beloit, KS 67420 $500.00 Steven Johnson for Kansas House Steven Johnson, STATE HOUSE 108th KS 10197 South Hopkins Road $500.00 09/11(2014 Assaria, KS 67416 Troy L. Waymaster for Kansas House Troy Waymaster, STATE HOUSE 109th KS 112 N Fairview Ave $500.00 09/11/2014 Luray, KS 67649 Ronald Ryckman for Kansas House Ronald Ryckman, STATE HOUSE 115th KS P.O Box 192 $500.00 09/11/2014 Meade, KS 67864 Kyle Hoffman for Kansas House Kyle Hoffman, STATE HOUSE 116th KS 1318 Avenue T 09/11/2014 $500.00 Coldwater, KS 67029 John Ewy for Kansas House John Ewy, STATE HOUSE 117th KS 09/11(2014 801 Roughton St. $500.00 Jetmore, KS 67854 Don Hineman for Kansas House Don Hineman, STATE HOUSE 118!h KS 09/11/2014 116 S Longhorn Rd $500.00 Dighton, KS 67839 Rick Billinger for Kansas House Rick Billi~ger, STATE HOUSE 121st KS 09/11(2014 310 Acacia Drive $500.00 Goodland, KS 67735 J. Russell Jennings for Kansas House J Jennings, STATE HOUSE 122nd KS 09/11/2014 515 Pleasntview $500.00 Lakin, KS 67830 $5,000.00 Page_7_of~ 01 / 09 / 2015 15:44 FAX Kansas Hospital Assoc 141021 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Pureose of Exeenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address Steve Alford for Kansas House J. Stephen Alford, STATE HOUSE 124th KS 4179 East Road 19 $500.00 09/11/2014 Ulysses, KS 67880 Jeff Longbine for Kansas Senate Jeff Longbine, STATE SENATE 17th KS PO Box 1903 09/11/2014 Emporia, KS 66801 $500.00 Vicki Schmidt for Kansas Senate Vicki Schmidt, STATE SENATE 20th KS 5906 SW 43rd Court $250.00 09/11/2014 Topeka, KS 66610-1632 Tom Arpke for Kansas Senate Tom Arpke, STATE SENATE 24th KS 512 West Iron Avenue $500.00 09/11/2014 Salina, KS 67401 Dan Kerschen for Kansas Senate Dan Kerschen, STATE HOUSE 26th KS 645 South 263 West $500.00 09/11/2014 Garden Plain, KS 67050 Wilborn for Senate Richard Wilborn, STATE SENATE 35th KS 1504 Heritage Place 09/11/2014 $500.00 McPherson, KS 67460 Elaine S. Bowers for Kansas Senate Elaine Bowers, STATE SENATE 36th KS 09/11/2014 1326 N 150th Rd $500.00 Concordia, KS 66901 Wiii Carpenter for Kansas House Will Carpenter, STATE HOUSE 75th KS 09/11/2014 6965 SW 1Bth St. $500.00 El Dorado, KS 67042 Kristey Williams for State Representative Krisley Williams, STATE HOUSE 771h KS 09/11/2014 21 Taylor Ave. $500 .00 Augusta, KS 67010 Connie O'Brien for Kansas House Connie O'Brien, STATE HOUSE 42nd KS 09/15/2014 22123 211th St. $500.00 Tonganoxie, KS 66086 $4 ,750.00 Page_B_of~ 01/ 09/ 2015 15 : 45 FAX Kansas Hospital Assoc !41022 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Pur(?oSe of ExEenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in~kind expenditure in excess of $300 is made for a candidate, list candidate name & address Dannebohm for Kansas House Jeremy Dannebohm, STATE HOUSE 113th KS 211 Craig Street $500.00 09/15/2014 Ellinwood, KS 67526 Milch Holmes for Kansas Senate Mitch Holmes, STATE SENATE 33rd KS 211 SE 20th Ave 09/15/2014 St. John, KS 67576 $250.00 Square Up Thomas Borrego 9/15/14 09/15/2014 $1 .38 Square Up Bryan Coffey 09/16/14 09/16/2014 $5.40 Square Up Robin Coffey 9/16/14 09/16/2014 $5.40 Square Up Dennis Shelby 9/18/14 09/18/2014 $2.75 Stephanie Clayton for Kansas House Stephanie Clayton, STATE HOUSE 19th KS 9825 Woodson Dr. 09/22/2014 $500.00 Overland Park, KS 66207 Rob Bruchman for Kansas House Rob Bruchman, STATE HOUSE 20th KS 5016 West 10BthTerrace 09/22/2014 #522 $250.00 Overland Park, KS 66211 Jerry D Lunn for Kansas House Jerry Lunn, STATE HOUSE 28th KS 14512 Horton SL 09/22/2014 $250.00 Overland Park, KS. 66223 James Todd for Kansas House James Todd, STATE HOUSE 29th KS 09/22/2014 9812 W. 118th St. $250.00 Overland Park, KS 66210 $2,014.93 Page_9_of~ 01 / 09 / 2015 15:45 FAX Kansas Hospital Assoc 141023 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Purf?OSe of Exf?enditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address Randy Powell for State Representative Randy Powell, STATE HOUSE 30th KS 14881 W. 122nd Street $250.00 09/22/2014 Olathe, KS 66062 Tom Burroughs for Kansas House Tom Burroughs, STATE HOUSE 33rd KS 3131 So. 73rd Terr 09/22/2014 Kansas City, KS 66106 $250.00 Dick Jones for Kansas House Dick Jones, STATE HOUSE 52nd KS 4231 Marlboro Rd. $250.00 09/22/2014 Topeka, KS 66610 Lonnie Clark for State Representative Lonnie Clark, STATE HOUSE 65th KS 824 B S. Madison $500.00 09/2212014 Junction City, KS 66441 Les Mason for Kansas House Les Mason, STATE HOUSE 73rd KS 108 Arcadian Ct. $250.00 09/22/2014 McPherson, KS 67460 Peggy Mast for Kansas House Peggy L. Mast, STATE HOUSE 76th KS 765 Road 11'0 09/22/2014 $250.00 Emporia, KS 66801 Bridges for Kansas House Carolyn Bridges, STATE HOUSE 83rd KS 09/22/2014 5219 E. First St. $250.00 Wichita, KS 67208 Gail Finney for Kansas House Gail Finney, STATE HOUSE 84th KS 09/22/2014 1754 N. Madison St $250.00 Wichita, KS 67214 Carmichael for Kansas John Carmichael, STATE HOUSE 92nd KS 1475 North Lieunett 09/2212014 $250.00 Wichita, KS 67203 Whitmer for Kansas John Whitmer, STATE HOUSE 93rd KS 09/22/2014 PO Box2862 $250.00 Wichita, KS 67201 $2,750.00 Page _10_ of~ 01 / 09/ 2015 15:45 FAX Kansas Hospital Assoc !41024 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Naine of Party Committee or Political Committee) PUr(!OSe of Ex(!enditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address Mario Goico for Kansas House Marlo Goico, STATE HOUSE 1001h KS 1254 North Pine Grove Ct. $250.00 09/22/2014 Wichita, KS 67212 Tom Sawyer for Kansas House Tom Sawyer, STATE HOUSE 95th KS 1041 S. Elizabeth St 09/22/2014 Wichita, 67213 $250.00 Joe Seiwert for Kansas House Joe Seiwert, STATE HOUSE 101st KS 1111 East Boundary Road 09/22/2014 Pretty Prairie, KS 67570 $250.00 Ponka-Wa Victors for Kansas House Ponka-W~ Victors, STATE HOUSE 103rd KS PO Box48081 $250.00 09/22/2014 Wichita, KS 67201 Kay Wolf for Kansas Senate Kay Wolf, STATE SENATE 7th KS 7921 Bristol Court 09/22/2014 Prairie Village, KS 66206 $500.00 . Jim Denning for Kansas Senate Jim Denning, STATE SENATE 6th KS 6416 West 11 SthStreet 09/22/2014 $250.00 Overland Park, KS 66210 Julia Lynn for Kansas Senate Julia Lynn, STATE SENATE 9th KS 09/22/2014 18837 W. 115th Terrace $500.00 Olathe, KS 66061 Jeff Melcher for Kansas Senate Jeff Melcher, STATE SENATE 11th KS 11424 Canterbury Circle 09/22/2014 $500.00 Leawood, KS 66211 Jacob La Turner for Kansas Senate Jacob LaTurner, STATE SENATE 13th KS 09/22/2014 204 E. Euclid St.. $500.00 Pittsburg, KS 66762 Greg Smith for Kansas Senate Greg Smith, STATE SENATE 21st KS 09/22/2014 8605 Robinson $500.00 Overland Park, KS 66212 $3,750.00 Page _1_1_ of~ 01 / 09 / 2015 15:46 FAX Kansas Hospital Assoc 141025 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action .Committee (Name of Party Committee or Political Committee) Purpose of Expenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address Robert Olson for Kansas Senate Robert Olson, STATE SENATE 23rd KS 19050 West 161 st Street 09/22/2014 Olathe, KS 66062 $500.00 Mike Petersen for Kansas Sen.ate Mike Petersen, STATE SENATE 28th KS 2608 Southeast Drive 09/22/2014 Wichita, KS 67216-2140 $500.00 Oletha Faust-Goudeau for Kansas Senate Oletha Faust-Goudeau, STATE SENATE 29th KS 4158 Regents Lane $250.00 09/22/2014 Wichita, KS 67208 Terry Bruce for Kansas Senate Terry Bruce, STATE SENATE 34th KS 401 East Sherman $250.00 09/2212014 Hutchinson, KS 67501 Garrett Love for Kansas Senate Garrett Love, STA TE SENATE 38th KS P.O. Box 1 $500.00 09/22/2014 Montezuma, KS 67867 Ralph Ostmeyer for Kansas Senate Ralph Ostmeyer, STATE SENATE 40th KS 602 S Jefferson 09/22/2014 $500.00 PO Box97 Grinell, KS 67738 Adam Lusker for Kansas House Adam Lusker, STATE HOUSE 2nd KS 09/22/2014 452 S. 210lh St. $250.00 Frontenac, KS 66763 Square Up John Moore, 9/23/14 09/23/2014 $6.88 Square Up Greg Unruh 09/23/14 09/23/2014 $9.63 Square Up Cindy Samuelson 09/23/14 09/23/2014 $0.03 $2 ,766.54 Page _12_ of~ 01 / 09 / 2015 15:46 FAX Kansas Hospital Assoc f4J026 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political Committee) Purl?ose of Ex(?enditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure.in excess of $300 is made for a candidate, list candidate name & address Square Up Chris Conrade 9/23/14 $11 .00 09/23/2014 Ravenwood Lodge Sporting Clay Shoot 9/23/14 10147 SW 61st Street $141.60 09/23/2014 Topeka, KS 66610 Square Up Luanne George 9/23/14 09/23/2014 $1.38 Square Up cs 9/23/14 09/23/2014 $0.03 Square Up Kiley Floyd 09/24/14 09/24/2014 $7.15 Larry R. Powell for Kansas Senate Larry R. Powell, STATE SENATE 39th KS 9555 N. Dewey Rd. 09/25/2014 $500.00 Kalvesta, KS 67835 Tom Holland for Kansas Senate Tom Holland, STATE SENATE 3rd KS 09/25/2014 961 E 1600 Rd $250.00 Baldwin City, KS 66006 John Wilson for Kansas House John Wilson, STATE HOUSE 10th KS 09/25/2014 1923 Ohio St. $250.00 Lawrence, KS 66046 Becky Hutchins for Kansas House Becky Hutchins, STATE HOUSE 61st KS 09/25/2014 407 New York Avenue $250.00 Holton, KS 66436 Square Up Eldon Koepke 9/26/14 09/26/2014 $2.75 $1 ,413.91 Page _13_ of~ Ul / 09 / 2015 15:46 FAX Kansas Hospital Assoc 141027 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association Politlcal Action Committee (Name of Party Committee or Political Committee) Purpose of Expenditure Name and Address Amount Date To Whom Expenditure is Made If independent or in-kind expenditure in excess of $300 is made for a candidate, list candidate name & address Square Up Jeremy Armstrong 09/26/14 $2.75 09/26/2014 Square Up BKD (Jason Barb & Matt Morris) 9/26/14 09/26/2014 $6.88 Square Up Michelle Bohannon 9/26/14 09/26/2014 $0.69 Michael Murphy and Sons Sporting Clay Shoot 9/26/14 6400 SW Hunter Road $169.83 09/26/2014 Augusta, KS 67010 $180.15 Page~of~ 01/ 09 / 2015 15 :47 FAX Kansas Hospital Assoc (4J 028 SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS Kansas Hospital Association PoliUcal Action Committee (Name of Party Committee or Political Committee) Name and Address Purpose of Expenditure Date To Whom Expenditure is Made Amount If independent or in·kind expenditure in excess of $300 is made for a candidate, list candidate name & address Republican House Campaign Committee 2025 SW Gage Blvd 09/29/2014 Topeka, KS 66603 $1,500.00 AHAPAC-American Hospital Association KHA to AHA PAC Transfer FEDERAL 09/30/2014 800 10th Street, NW $1,894.55 Two City Center, Suite 400 Square Up Barbara Waggoner 09/30/14 09/30/2014 $0.69 Square Up William Widener 09/30/14 09/30/2014 $6.88 Square Up Richard Kraemer 10/ 11 /14 10/11/2014 $13.75 Square Up Kanna Huck 10/03/14 10/17/2014 $2.75 Square Up Bruce Will 10/6/14 10/17/2014 $2.75 Shannon Francis for Kansas House Shannon Francis, STATE HOUSE 125th KS 1501 Tucker Court 10/22/2014 Liberal, KS 67901 $500.00 $3 ,921 .37 Complete if last page of Schedule c Total Itemized Expenditures This Period $56,037.75 Total Unitemized Expenditures of $50 or less $35.76 $56,073.51 Page _15_ of_2:._