r FILEIf'A~S GOVERNMENTAL ETHICS COMMISSION R.ECEIPTS AND EXPENDITURES REPORT JAN {} 92018 bF A POLITICAL OR PARTY COMMITTEE KA/s W. KOBACH January 10,2018 L ECRETARY OF STATE I - FILE WITH SECRETARY OF STATE SEE REVERSE SIDE FOR INSTRUCTIONS

A. NftJDe of CQmmittcc: ~A.~anS8' Good ~O~8mm.~un~ . _ Address: clo 5845 SW 29th Street

City and Zip Code: Topeka 66614·2462

This is a (check one): _.._ Party Committee ~ Political Committee

B. Check only ifappropriate: __" Amended Filing __Termination Report

C. Summary (covering the period from January 1,2017 tbrough December 31,1017) L. Cash on hand at beginning ofperiod .. 16732.02 2. Total Contributions and Other Receipts (Use Schedule A) .. 45000.00 3. Cash available this period (Add Lines I and 2) . 81732.02 36550.00 4, Total Expenditures and Ocher Disbursements (Usc Schedule C) .. --'_.'-_._"'-' 5. Cash on hand at close of period (Subtract Line 4 tiom 3) . 25182.02 6. In-Kind Contributions (Use Schedule '9) 0.00 7. Other Trrmsllctions (Use Schedule D) !:OO

D. "r declare that this report, including any 8ccompanyins schedules and statements, has been e~l1mined by me and to the best of my knowIed80 and belief is true, correct and complete. I understand that the intentionlll failure to tile this document or intentionally flUng a false document is a class A misdemeanor,"

S;gnttture ofTrcasurer I I .1 GEe Form Rev, 20)7 I I I i I I SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS HCA Kansas Good Government Fund (Name of Party Comml;.ee or PolitIcal Commlnee)

Occupation of Check Amount of Name and Address Individual GIving More Appropriate Bol Cash. Check. Dafe or Contributor Than $150 Loan or Otber C..h Chell ~. Eroad, Ot'­ Re(elpt enorah Medical Center Hospital 08/15/17 5721 West 119th Street $11.250.00 Overland Park KS 66221 V

Overland Park Regional Med etr HospItal 08/21/17 10500 Quivira $11.250.00 Overland Park KS 66215 V

Wesley Medical Center Hospital 08/28/17 550 N. Hillside V $22.500.00 Wichita KS67214

$45,000.00

Complete if last page of Schedule A

Total Itemized Receipts for Period $45.000.00

Total Unilemized Contributions ($50 or less)

Sale of Political Malenals (Unitemized)

Total Contributions When Contributor Not Known

Page __of__ SCHEDULEC EXPENDITURES AND OTHER DISBURSEMENTS HCA Kansas Good Govemment Fund ( Name of Party Committee or Political Committee)

Name and Address Purpose of EllpendUure Date To Whom Expendlturt is Made Amount IfIDdepeade.t or In-JUnd expendIture In eseesl of 5300 Is made for a c:aDdldate, Ust candl.date name" addret. See attachment to Schedule C $36,550.00

$36,550.00

Complete If last page ofSchedule C

Total itemized Expenditures This Period $38,550.00

Total Unitomized Expenditures of $50 or loss

$36,550.00

Pagc __of__ HCA Kansas Good Government Fund SCHEDULEC EXPENDITURES AND OTHER_._- DISBURSEMeNTS ­ D." Name HameAdd,.._ Amount Jan· De~ 17 0612612017 Governmenta' Ethics Comml••lon 901 S. Kan..s lit Floor Topeka, KS 66612 300.00­ 08/0712017 Hawtt-In. for State RepresentatIve Rep. Daniel Hawl