KANSAS GOVERNMENTAL ETHICS COMMISSION RECEIPTS AND EXPENDITURES REPORT RECEIVED OF A POLITICAL OR PARTY COMMITTEE July 30, 2012 JUl 2'7 20\2 mi FILE WITH SECRETARY OF STATE KS Governmental EthiCS Com sian 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_pe_ka_,_66_6_01 u_s _ 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 January 1, 2012 through July 26, 2012) l. Cash on hand at beginning ofperiod .. $84,199.65 2. Total Contributions and Other Receipts (Use Schedule A) : . $16,906.06 3. Cash available this period (Add Lines 1 and 2) . $101,105.71 4. Total Expenditures and Other Disbursements (Use Schedule C) .. $32,612.06 5. Cash on hand at close ofperiod (Subtract Line 4 from 3) .. $68,493.65 6. In-Kind Contributions (Use Schedule B) ......... $2,438.90 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 ;1:;;~: ,~s document or m~;::?::z:t:n: is~t~:::Sdemeanor" .' . ~d ~JLY w~o fYl.ec~ic,.JI " oJ"M L8::. >-U Date SigoatureU,fTreasurer;;:." 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 Organization of Nurse Leaders Kansas Nursing Professional Association $276.00 KS 01/06/2012 Risk & Quality Mgt KS Assoc of Risk & Quality Management $100.00 CoO Kansas Hospital Association Association 01/06/2012 PO BOX 2308 Topeka, KS 66601-2305 Teresa Deuel Chief Executive Officer 5120.00 POBox310 01/06/2012 Jetmore, KS 67854-0310 Kansas Healthcare Engineers Association Professional Association $500.00 PO Box 308 01/06/2012 Newton, KS 67114-0308 Samuel Turner Chief Executive Officer $500.00 Box 2923 01/31/2012 Shawnee Mission, KS 66201-1323 Patricia Stevenson Manager, Quality Management $100.00 21308 W. 51 sl. Street 01/31/2012 Shawnee Mission, KS 66218·9089 Robin Harrold Senior Vice President $150.00 0113112012 13402 W. 72nd SI. Shawne.e, KS 66216-4158 Bradley Hoffman Hospital Employee $100.00 01/31/2012 7811 Alden Rd. Lenexa, KS 66216-4277 Sheri Hawkins Vice President $100.00 01/31/2012 14013 West 72nd Street Shawnee, KS 66216-3781 David Gregory Adm Director $75.00 01/31/2012 27085 West 226th Street Spring Hill, KS 66083-9190 arry Botts Chief Medical Officer $100.00 02/02/2012 P200 W 68th St Mission Hills, KS 66208-2135 . c _ . .::. $2,121.00 Page 1 of 6 -- -- 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 Doug Spear Director of Marketing $100.00 12815 S Rene St 02/02/2012 Olathe, KS 66062-6223 .f Albert Dudley Adm. Director $100.00 16108 Linden SI. 02/02/2012 Stilwell, KS 66085-9399 .f Steven Poage Vice PresidenUCFO $500.00 3401 SW Alameda 03/07/2012 Topeka, KS 66614-5109 .f Randall Peterson President and Chief Executive $1,000.00 1500 SW Tenth Avenue Officer 03/22/2012 Topeka, KS 66604-1301 .f Jodi Schmidt President $100.00 1902 S. U.S. Hwy. 59P.O. Box 956 03/22/2012 Parsons, KS 67357-0956 .f Mark Miller Chief Executive Officer $350.00 511 NE Tenth Street 03/22/2012 Abilene, KS 67410-2153 .f Chad Austin Vice President, Government $115.38 03/22/2012 6518.SW 26th Court Relations Topeka, KS66614-4305 .f Thomas Bell President and Chief Executive $115.38 03/22/2012 215 Southeast 8th Avenue Officer Topeka, KS 66603-3906 .f Melissa Hungerford Sr. Vice President $115.38 03/22/2012 6448 SW Bayshore Dr Aubum, KS 66402-9324 .f Fred Lucky Senior Vice President $230.76 03/22/2012 14607 W 89 Lenexa, KS 66215-2967 .f ~indy Samuelson Vice President $57.72 03/22/2012 1107 NE 54th SI tropeka, KS 66617-4505 $2,784.62 Page _2__ of_6__ 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 Mark Praeger Surgeon 5100.00 330 Arkansas St Ste 202 03/22/2012 Lawrence, KS 66044-1394 .f Leonard Hernandez Chief Executive Officer $500.00 445 Hilltop Street 03/26/2012 Elkhart, KS 67950-0937 .f Associated Purchasing Services APS GPO 52.000.00 215 South East Eighth 06/04/2012 Topeka, KS 66603 .f Associated Purchasing Services APS GPO $2,000.00 215 South East Eighth 06/04/2012 Topeka, KS 66603 .f Ron Bender Chief Executive Officer $350.00 POBox512 06/11/2012 Clay Center, KS 67432-0512 .f John Jacobson Chief Executive Officer 5250.00 06/11/2012 800 Raven Hill Drive Atchison, KS 66002-9204 .f John Broberg President and Chief Executive 5500.00 06/18/2012 1020 Parkshire Cir Officer Manhattan, KS 66503-2475 .f Greg Lundstrom Director of Hospital Relations 5500.00 06/18/2012 605 West Lincoln Street Lindsborg, KS 67456-2328 - .f Dennis Franks Chief Executive Officer 5200.00 06/18/2012 PO Box 426 Chanute, KS 66720-0426 .f Susan Page President and Chief Executive $350.00 06/18/2012 200 Commodore Street Officer Pratt, KS 67124-2903 .f Chad Austin Vice President, Government 5134.61 06/26/2012 ~518 SW 26th Court Relations Iropeka, KS 66614-4305 ./ .. ,,.., ·,i,'·';'" ',"," i,. ',.' 'i "'..'.. .. ",;>'," ...•..• $6,884.61 ,"'..,"";; Paoe0 3 of 6 _ 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 Thomas Bell President and Chief Executive $134.61 215 Southeast 8th Avenue Officer 06/26/2012 Topeka, KS 66603-3906 Melissa Hungerford Sr. Vice President $134.61 6448 SW Bayshore Dr 06/26/2012 AUburn, KS 66402-9324 Fred Lucky Senior Vice President $269.22 14607 W 89 06/26/2012 Lenexa, KS 66215-2967 Sally Perkins Director of Data Services $26.95 1725 NW Grove 06/26/2012 Topeka, KS 66606-1237 Cindy Samuelson Vice President $67.34 1107 NE 54th St 06/26/2012 Topeka, KS 66617-4505 .f Terrie W. Huntington for State Senate $250.00 07109/2012 PO Box 8378 Praire Village, KS 66208 St Johns Maude Norton Memorial Hospital community hospital $200.00 07/24/2012 220 North Pennsylvania Columbus, KS 66725-1110 .f Kevin Han Director, Financial Management $500.00 07/24/2012 6200 SW 34th Terr. Topeka, KS 66614-4667 William Miller Board member $200.00 07/24/2012 1193 Four Mile Rd. Council Grove, KS 66846-8719 .f Diane Burton Director $100.00 07/24/2012 5602 SW Timberlake Ct. Topeka, KS 66614-4537 .f Jill Straub Health Information Management $100.00 07/24/2012 17907 SW 28th Street Director opeka. KS 66614-4891 $1,982.73 Page _4__ of_6__ 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· Cbeck Loan E funds Other Receipt Robert O'Neil Medical Advisor $350.00 1401 SW Pembroke Lane 07/24/2012 Topeka, KS 66604-2535 - Lenora Kinzie Director, Library Services $100.00 1267 Medford 07/24/2012 Topeka, KS 66604-1517 Hiawatha Community Hospital Hospital Contribution $200.00 300 Utah 07/24/2012 Hiawatha, KS 66434-2314 $650.00 ...;:.. Page ~5__ of_6__ 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 Olher Receipt James Reagan Chief Executive Officer $350.00 600 North Washington Street 07/24/2012 Council Grove, KS 66846-1422 t/ Cheyenne County Hospital Community Hospital $200.00 210 W. First Sl. 07/24/2012 PO Box 547 ~ Saint Francis, KS 6~756-3540 Carrie Saia CNO 5100.00 1110 Columbine Dr 07/24/2012 Holton, KS 66436-8824 t/ Grisell Memorial Hospital community hospital $200.00 210 S Vermont 07/24/2012 Ransom, KS 67572-9525 ~ Bernard Becker VPIChief Human Resources $500.00 4527 SW Crenshaw Dr. Officer 07/24/2012 Topeka, KS 66610-1615 t/ - Carol Wheeler Vice President $350.00 1248 SW Westside Drive 07/24/2012 Topeka, KS 66615-1236 t/ Lisa Carlton Director $100.00 07/24/2012 5534 NE Indian Creek Rd Topeka, KS 66617-1604 ~ Jane Mackey President & Executive Director $100.00 07/24/2012 3817 SW Clarion Park Topeka, KS 66610-1278 .f ,"""", ",{",.:;" ~:']\;,::) ~k ii,'·' "" ,t,::;;: ,,,.,, ':,,~;i:f,i:!:;i!' $1.900.00 1~i.