KANSAS GOVERNMENTAL ETHICS COMMISSION RECEIPTS AND EXPENDITURES REPORT OF A POLITICAL OR PARTY COMNIITTEE October 29,2012 FILE WITH SECRETARY OF STATE SEE REVERSE SIDE FOR INSTRUCTIONS A. Name of Committee: Kansas Hospital Association Political Action Committee Address: 215 SE 8th Street City and Zip Code: T_o_p_ek_a,_6_66_0_1 us _ This is a (check one): __Party Committee x Political Committee B. Check only if appropriate: __ Amended Filing __ Termination Report C. Summary (covering the period from July 27,2012 through October 25, 2012) $70,193.65 1. Cash on hand at beginning of period . 2. Total Contributions and Other Receipts (Use Schedule A) .. $33,315.68 3. Cash available this period (Add Lines I and 2) . $103,509.33 4. Total Expenditures and Other Disbursements (Use Schedule C) .. $43,089.62 5. Cash on hand at close of period (Subtract Line 4 from 3) .. $60,419.71 6. In-Kind Contributions (Use Schedule B) . $6,459.40 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 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." '. ­ Date Signature of Treasurer GEe Form Rev, 2001 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 Other Receipt Kathleen Harr Dean & Professor $100.00 3732 SW Herefordshire Road 08/15/2012 Topeka, KS 66610-1541 .f Curt Colson President and Chief Executive $100.00 508 N Maple St Officer 08/15/2012 Hoisington, KS 67544-2150 .f Jane Schepmann CNO $100.00 300 W Santa Fe 08/15/2012 Holyrood, KS 67450-9657 .f Dana Hale Vice President Nursing $100.00 670 N. 1505 Rd. 08/15/2012 Lawrence, KS 66049-9121 .f Sheryle D'Amico VP $350.00 737 N. 1550 Rd. 08/15/2012 Lawrence, KS 66049-9198 .f Karen Shumate Chief Operating Officer $100.00 1753 E 980 Rd 08/15/2012 Lawrence, KS 66049-9073 .f Washington County Hospital Community Hospital $200.00 08/15/2012 304 E. 3rd Washington, KS 66968-2033 .f Kenneth Stone Director of Corporate Compliance $150.00 08/21/2012 2543 SE Faxon Ct. and Finance Topeka, KS 66605-2086 .f Karlene Lockard Director $100.00 08/21/2012 1114 SW Garfield Topeka, KS 66604-1312 .f Kathleen Willis VP/CDO $150.00 08/21/2012 1071 E 1400 Rd Lawrence, KS 66046-9633 .f Carolyn Bowmer Vice President, Human Resources $100.00 08/21/2012 17301 West 84th Terrace Lenexa, KS 66219-8046 .f $1,550.00 Subtotal This Page Page _1__ of~ SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association 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 Kathy Howell Vice President & Chief Nursing $350.00 12867 Barton Officer 08/21/2012 Overland Park, KS 66213-4424 .f Carla Yost Chief Operating Officer $200.00 1823 College Ave. 08/21/2012 POBox 1289 Manhattan, KS 66502-3381 .f Eric Voth Physician $350.00 411 Woodbury Court 08/21/2012 Topeka, KS 66606-2192 .f Gayle Arnett CEO $350.00 1819 Ridge Road 08/21/2012 EI Dorado, KS 67042-4033 .f Eugene' Meyer President and Chief Executive $500.00 325 Maine Street Officer 08/21/2012 Lawrence, KS 66044-1360 .f Edward Smink Director $100.00 526 Carnpusview St 08/21/2012 Garden City, KS 67846-8559 .f Joseph Pedley VP/CFO $100.00 08/21/2012 5624 Villa Drive Lawrence, KS 66047-8300 .f Ness County Hospital Community Hospital $200.00 08/21/2012 312 Custer Ness City, KS 67560-1654 .f Lane County Hospital Community Hospital $200.00 08/21/2012 235 West Vine PO Box 969 .f Dighton, KS 67839-0969 Charles Grimwood Vice President $100.00 08/21/2012 115 Mt. Barbara Rd. Salina, KS 67401-3414 .f David Moody Vice President, Human Resources $100.00 08/21/2012 ~10 Winn Road Isalina, KS 67401·3668 .f $2,550.00 Subtotal This Page Page _2__ of~ SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association Political Action Committee (Name of Party Committee or Political ConU11ittee) 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 Melissa Atkins Chief Executive Officer $100.00 304 West Prout Street 08/21/2012 Hill City, KS 67642-1435 .; LoJean Oleen Trustee $200.00 317 S KS. Hwy. 4 08/21/2012 .; Janet Stanek Sr. Vice President $1,000.00 6755 SW Dancaster Road 08/21/2012 Topeka, KS 66610-1412 .; Blaine Miller Administrator $100.00 2420 'G' Street 08/21/2012 Belleville, KS 66935-2400 .; Kent Palmberg Senior Vice President and Chief $500,00 1500 SW Tenth Avenue Medical Officer 08/21/2012 Topeka, KS 66604-1301 .; Tom Jernigan Veterinarian $200.00 925 T Avenue 08/21/2012 Council Grove, KS 66846-8777 .; William Dickson Hospital Trustee $200,00 08/21/2012 610 Pondway Council Grove, KS 66846-1560 .; Bonnie Thomas Trustee $200.00 08/21/2012 331 ABAve Council Grove, KS 66846-8334 .; Robert Brazil Chief Operating Officer $100.00 08/21/2012 511 NE Tenth Street Abilene, KS 67410-2153 .; Patricia Berns Hospital Employee $100.00 08/21/2012 2570 Hwy. 15 Abilene, KS 67410-6035 .; Elgin Glanzer Chief Financial Officer $100.00 08/21/2012 ~11 NE Tenth Street Abilene, KS 67410-2153 .; $2,800.00 Subtotal This Page Page _3__ of~ SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association 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 judy Wagner Vice President $100.00 912 Davis Drive 08/21/2012 Manhattan, KS 66502-8005 .f Don Harmison Trustee $200.00 1081 Hwy 149 08/21/2012 White City, KS 66872-9413 .f Lora Key Chief Executive Officer $200.00 POBox 229 08/21/2012 Sabetha, KS 66534-0229 .f Tom Bell Executive Director of Public $100.00 1215 Columbine Lane Relations 08/21/2012 Salina. KS 67401-9108 .f Vicky McGrath Director $100.00 211 W 11th 08/21/2012 Auburn, KS 66402-9477 .f Richard Vaught Administrator $100.00 1300 East Fifth Street 08/21/2012 Winfield. KS 67156-2407 .f Michael Kongs Director Financial Management $100.00 08/21/2012 7261 SW Fountaindale Topeka, KS 66614-4629 .f Judy Corzine Administrative Director and Chief $400.00 08/21/2012 3621 SW Woodvalley Place Information Offi Topeka, KS 66614-3536 .f John Hinnenkamp Department Manager $100.00 08/21/2012 3155 W. Crawford SI. Salina, KS 67401-9706 .f Anthony Medical Center Community Hospital $200.00 08/21/2012 1101 E. Spring SI. Anthony. KS 67003-2122 .f Sunflower Chapter HFMA Professional Association $500.00 08/30/2012 PO Box 2196 f/vichita. KS 67201-2196 .f $2,100.00 Subtotal This Page Page _4__ of~ SCHEDULE A CONTRIBUTIONS AND OTHER RECEIPTS Kansas Hospital Association 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 Adele Ducharme CNO $250.00 2218 NW 81st Ct 08/30/2012 Kansas City, MO 64151-3700 .f Derwood Whittington VP of HR $100.00 2220 Canterburry 08/30/2012 Hays, KS 67601-2370 .f Bryce Young Chief Operating Officer $100.00 POBox 8100 08/30/2012 Hays, KS 67601-8100 .f Terry Siek Chief Nursing Officer $100.00 300 W. 21st 08/30/2012 Hays, KS 67601·3004 .f Ashland District Hospital KS Community Hospital $200.00 PO Box 188 08/30/2012 709 Oak Street Ashland, KS 67831-0188 .f Dean Miller Trustee $200.00 08/30/2012 1925 S 2500 Rd Herington, KS 67449 .f Ninnescah Valley Health Systems Community Hospital $200.00 08/30/2012 750 West D. Avenue Kingman, KS 67068-1266 .f Victoria Hahn Administrator and Chief Executive $200.00 08/30/2012 211 East Earl Street Officer Leoti, KS 67861-9620 .f Roger John President and Chief Executive $500.00 08/30/2012 POBox 366 Officer Phillipsburg, KS 67661-0366 .f Logan County Hospital Community Hospital $100.00 08/30/2012 211 Cherry Oakley, KS 67748-1201 .f ~ohn Harris Partner $500.00 08/30/2012 1551 N. Waterfront Parkway, Suite 300 Wichita, KS 67206-4467 { $2,450.00 Subtotal This Page Page _5__ of~ 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 Other Receipt Jon Jackson Sr. Vice President, Systems $350.00 8000 Tomahawk Road Intergration 08/30/2012 Prairie Village, KS 66208-4845 .f Bob Page Chief Executive Officer $1,000.00 3901 Rainbow Boulevard 08/30/2012 Kansas City, KS 66160-0001 .f Roger Masse Chief Executive Officer $120.00 410 Court Ave 08/30/2012 Ellsworth, KS 67439-0087 .f Vallerie Gleason VP $100.00 3123 N.