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Electronic Filing

SEEC FORM 20
Itemized Campaign Finance Disclosure Statement
CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION
Revised January 2015

Do Not Mark in This Space For Official Use Only

Page 1 of 26

COVER PAGE
1. NAME OF COMMITTEE
Ansonia Republican Town Committee

2. TREASURER NAME
First
Linda

MI

Last

Vaccaro

Suffix

3. TREASURER ADDRESS
Street Address

City

State

Zip Code

515 Beaver St

Ansonia

CT

06401

4. ELECTION/REFERENDUM DATE

5. OFFICE SOUGHT (Complete only if Candidate Committee)

6. DISTRICT NUMBER (if applicable)

7. CANDIDATE NAME (Complete only if Candidate or Exploratory Committee)


First

MI

Last

Suffix

8. TYPE OF REPORT
October 10 Filing - Original

9. PERIOD COVERED

Beginning Date

07/01/2015

Ending Date

thru

09/30/2015

10. CERTIFICATION

I hereby certify and state, under penalties of false statement, that all of the information set forth on this
Itemized Campaign Finance Disclosure Statement for the period covered is true, accurate and
complete.

Electronic Filing

Linda Vaccaro

10/09/2015

7:37:19PM

SIGNATURE

PRINT NAME OF THE SIGNER

DATE CERTIFIED

A Person who is found to have knowingly and willfully violated any provisions of the campaign finance statutes faces a civil
penalty or imprisonment or both.

Page 2 of 26

SEEC FORM 20
Itemized Campaign Finance Disclosure Statement
CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION
Revised January 2015

SUMMARY PAGE TOTALS


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)
Ansonia Republican Town Committee

TYPE OF REPORT
October 10 Filing - Original

COLUMN A

COLUMN B

This Period

Aggregate

11. Balance on hand January 1 of current year for Ongoing and Party Committees OR
Balance on hand from day Committee was formed for all other Committees

$1,774.85

12. Balance on hand at the beginning of Reporting Period

$2,699.85

13. Contributions received from Individuals (Section A and B)

$6,454.00

$7,654.00

$250.00

$250.00

$2,496.00

$2,496.00

14. Receipts from Other Committees (Sections C1 and C2)


15. Other Monetary Receipts (Section D through K)
16a. Total Proceeds from Small Puchases (Section L1 Subpart 1 + Subpart 3)

$0.00

$0.00

16b. Per Public Act 11-48, effective January 1,2012 Section L2 removed
16c. Total Purchases of Advertising - Program Book or Sign (Section L3)

17. Total Monetary Receipts (add totals for lines 13 through 16c)
18. Subtotals (add totals in Line 12 + 17 in Column A and in Line 11 + 17 in Column B)
19. Expenses Paid by Committee (Section P)
20. Balance on hand at close of Reporting Period (Subtract line 19 from line 18 in both colum
21. In-Kind Donations not Considered Contributions Received (Section L4)
22. In-Kind Donations not Considered Contributions - House Party (Section L5)
23. In-Kind Contributions Received (Section M)
24. Refundable Deposit to Telephone Company (Section N)
25. Loan Balance

$0.00

$0.00

$9,200.00

$10,400.00

$11,899.85

$12,174.85

$10,981.09
$918.76
$0.00
$0.00

$11,256.09
$918.76
$0.00
$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

25a. + Loans Received (Section D)

$0.00

$0.00

25b. + Interest and Penalties on Loan(s)

$0.00

$0.00

25c. - Payments on Loan

$0.00

$0.00

25d. Total Outstanding Loan Amount

$0.00

26. Campaign Expenses Paid By Candidate (Section Q)

$0.00

$0.00

$0.00

$0.00

27. Expenses Incurred on Committee Credit Card (Section R)


28. Expenses Incurred by Committee During this Period but Not Paid (Section S)
28a. Total Outstanding Expenses Incurred by Committee still Unpaid (Section S)

$0.00
$0.00

Page 3 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

A. Total Contributions from Small Contributors-Received this Period ONLY


(See instructions for definition of Small Contributor)

$0.00

Subtotal Section A

B. Itemized Contributions from Individuals


Last Name

First Name

Radin
Residential Street Address

Ansonia

Principal Occupation

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

If yes, indicate which branch or branches of


government the contract is with:

Executive

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative
Aggregate Contributions

07/23/2015

$200.00

$200.00
MI

Irving

Residential Street Address

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Quality Mgr

Materials Testing Inc

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

City

14 Highland Ave

_
_

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

07/23/2015

$100.00

$100.00

First Name

Vaccaro

MI

Lorie

Residential Street Address

City

515 Beaver St

Ansonia

Principal Occupation

State

Zip Code

CT

96488

Name of Employer

Retired

none

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
Cash

06401

First Name

Reed

_
_

Date Received

Last Name

Cash

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution

Zip Code

CT

Lear Pharmacey

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

State

Name of Employer

Pharmacist

Cash

City

198 Wakelee Ave

MI

Joan

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

08/09/2015

Aggregate Contributions

$500.00

$500.00

Page 4 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

Fers
Residential Street Address

Ansonia

Principal Occupation

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No
_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

If yes, indicate which branch or branches of


government the contract is with:

Executive

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative
Aggregate Contributions

08/09/2015

$50.00

$50.00
MI

Sheila

Residential Street Address

Oakville

Principal Occupation

State

Zip Code

CT

06779

Name of Employer

Grant Writer

City of Ansonia

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

City

37 Booth Ave Unit 7

_
_

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

08/09/2015

$25.00

$25.00

First Name

Cassetti

MI

Anthony

Residential Street Address

City

88 Franklin St

Ansonia

Principal Occupation

Zip Code

CT

06401

Birmingham Const. LLC

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

State

Name of Employer

Construction

Cash

06401

First Name

O'Malley

_
_

Date Received

Last Name

Cash

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution

Zip Code

CT

State of CT- Dept. of Childrens and Families

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

State

Name of Employer

Paralegal Specialist II

Cash

City

28 W Brookside Ave

MI

Patricia

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

08/09/2015

Aggregate Contributions

$500.00

$500.00

Page 5 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

Marini
Residential Street Address

City

11 Hawley Dr .

Ansonia

Principal Occupation

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

If yes, indicate which branch or branches of


government the contract is with:

Executive

_
_

06401

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

08/09/2015

$100.00

$100.00

First Name

Martin

MI

Gregory

Residential Street Address

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Graphic Artist
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?

Self Employed
_

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

City

13 Granite Ter

Cash

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution

Zip Code

CT

HMPB Law

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Cash

State

Name of Employer

Attorney

MI

Nancy

_
_

Credit/Debit Card

Payroll Deduction

Money Order

Last Name

Amount of Contribution

No

No

Legislative

Date Received

Personal Check

Yes

Yes

Aggregate Contributions

08/09/2015

$50.00

$50.00

First Name

Prestiano

MI

James

Residential Street Address

City

58 Morningside Dr .

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Retired
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
_

Cash

Personal Check

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

08/09/2015

Aggregate Contributions

$25.00

$25.00

Page 6 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

VITARIUS WAUGH
Residential Street Address

City

83 Prospect St

Ansonia

Principal Occupation

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No
_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

If yes, indicate which branch or branches of


government the contract is with:

Executive

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Amount of Contribution

No

No

Legislative
Aggregate Contributions

08/09/2015

$200.00

$200.00
MI

City

162 Center St

Woodbridge

Principal Occupation

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

State

Zip Code

CT

06525

Name of Employer

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

_
_

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

08/09/2015

$25.00

$25.00

First Name

Villers

MI

Ralph

Residential Street Address

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

City

33 Upland Ter

Cash

Yes

Yes

WARNER

Residential Street Address

06401

First Name

PYNE

Cash

_
_

Date Received

Last Name

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution
X

Zip Code

CT

LH Brenner

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

Cash

State

Name of Employer

Insurance Agent

MI

JANET

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

08/09/2015

Aggregate Contributions

$25.00

$25.00

Page 7 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

Nicolari
Residential Street Address

City

167 Pulaski Hwy

Ansonia

Principal Occupation

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No
_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

If yes, indicate which branch or branches of


government the contract is with:

Executive

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Amount of Contribution

No

No

Legislative
Aggregate Contributions

08/09/2015

$300.00

$300.00
MI

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
_

City

8 Sharyl Dr

_
_

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

08/09/2015

$40.00

$40.00

First Name

Carroll

MI

Randolph

Residential Street Address

City

40 Fourth St # 10

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Retired

Retired

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
Cash

Yes

Yes

Melissa

Residential Street Address

06401

First Name

Torres

Cash

_
_

Date Received

Last Name

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution
X

Zip Code

CT

Self Employed

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

Cash

State

Name of Employer

Real Estate Broker

MI

Judy

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

08/09/2015

Aggregate Contributions

$20.00

$20.00

Page 8 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

Henri
Residential Street Address

City

16 Harris Rd .

Ansonia

Principal Occupation

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No
_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

If yes, indicate which branch or branches of


government the contract is with:

Executive

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Amount of Contribution

No

No

Legislative
Aggregate Contributions

08/09/2015

$50.00

$50.00
MI

City

106 Pulaski Hwy

Ansonia

Principal Occupation

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
_

State

Zip Code

CT

06401

Name of Employer

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

_
_

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

08/09/2015

$50.00

$50.00

First Name

Rodriguez
City

108 Arthur St

Bridgeport

Principal Occupation

State

Zip Code

CT

06605

Name of Employer

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
_

MI

Jonathan

Residential Street Address

Cash

Yes

Yes

Anna

Residential Street Address

06401

First Name

Andretta

Cash

_
_

Date Received

Last Name

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution
_

Zip Code

CT

Sikorsky Aircraft

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

Cash

State

Name of Employer

Electric Designer

MI

Patrick

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

08/09/2015

Aggregate Contributions

$25.00

$25.00

Page 9 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

Conti
Residential Street Address

City

7 Buswell St

State

Ansonia

Principal Occupation

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

If yes, indicate which branch or branches of


government the contract is with:

Executive

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

First Name

John

Residential Street Address

No

Legislative
Aggregate Contributions

$25.00

$25.00
MI

State

Zip Code

CT

06401

Name of Employer

Regional Prop. Mgr.


Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?

Owens, Renzi Lee


_

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution

_
_

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

08/12/2015

$189.00

$189.00

First Name

Tripp

MI

Philip

Residential Street Address

City

57 Eagle St

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Sales

Home Depot

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
Cash

Amount of Contribution

No

Ansonia

Principal Occupation

Yes

City

12 Shortell Dr

Yes

08/09/2015

Izzo

Cash

_
_

Date Received

Last Name

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution
Cash

Zip Code

CT

Name of Employer

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

MI

Beth

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

08/13/2015

Aggregate Contributions

$100.00

$100.00

Page 10 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

O'Malley
Residential Street Address

Oakville

Principal Occupation

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

If yes, indicate which branch or branches of


government the contract is with:

Executive

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative
Aggregate Contributions

08/13/2015

$1,000.00

$975.00
MI

Joseph

Residential Street Address

City

72 Root Ave

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Retired

Retired

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution

_
_

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

08/14/2015

$1,000.00

$1,000.00

First Name

BIASUCCI
City

57 Rockwood Ave

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

REGISTERED NURSE
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?

YALE NEW HAVEN HOSPITAL


_

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

MI

NATALIE

Residential Street Address

Cash

06779

First Name

Cassetti

_
_

Date Received

Last Name

Cash

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution

Zip Code

CT

City of Ansonia

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

State

Name of Employer

Grant Writer

Cash

City

37 Booth Ave Unit 7

MI

Sheila

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

09/03/2015

Aggregate Contributions

$400.00

$400.00

Page 11 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

CZECZOT
Residential Street Address

City

37 Morningside Dr

Ansonia

Principal Occupation

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No
_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

If yes, indicate which branch or branches of


government the contract is with:

Executive

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Amount of Contribution

No

No

Legislative
Aggregate Contributions

09/03/2015

$100.00

$100.00
MI

City

14 Highland Ave

Ansonia

Principal Occupation

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Zip Code

CT

06401

Materials Testing
_

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

State

Name of Employer

quality control manager

_
_

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative

Date Received

Last Name

Aggregate Contributions

09/04/2015

$250.00

$250.00

First Name

Cassetti

MI

Gary

Residential Street Address

City

102 Root Ave

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Retired

Retired

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
Cash

Yes

Yes

Irving

Residential Street Address

06401

First Name

Reed

Cash

_
_

Date Received

Last Name

Is contributor a principal of state contractor or prospective state contractor?

Method of Contribution
X

Zip Code

CT

YALE UNIVERSITY

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

Cash

State

Name of Employer

SR. ADMIN ASST

MI

JOANNE

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

Amount of Contribution

No

Legislative

Date Received
_

Yes

Yes

09/09/2015

Aggregate Contributions

$1,000.00

$1,000.00

Page 12 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

B. Itemized Contributions from Individuals


Last Name

First Name

Monaco

MI

Silvana

Residential Street Address

City

6 S Cliff St

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Retired
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

_
X

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes
No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
_

Cash

Personal Check

Credit/Debit Card

Payroll Deduction

Money Order

Yes

Yes

Amount of Contribution

No

No

Legislative
Aggregate Contributions

09/17/2015

$100.00

$100.00

First Name

WHEELER
City

53 Benz St

Ansonia

Principal Occupation

State

Zip Code

CT

06401

Name of Employer

Is contributor a lobbyist, spouse,


or dependent child of a lobbyist?

Yes

No

Is this contribution associated with an


event reported in Section L1?
If yes, list Event #

If contribution is in excess of $400 to a candidate committee for a chief executive


officer of a municipality does contributor or business he/she associated with have
a contract with said municipality valued at more than $5000?

Yes

No

Personal Check

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Executive

Method of Contribution
X

MI

GORDON

Residential Street Address

Cash

_
_

Date Received

Last Name

_
_

Credit/Debit Card

Payroll Deduction

Money Order

No

No

09/18/2015

Aggregate Contributions

$30.00

Total of Section B

TOTAL OF ALL CONTRIBUTIONS FROM INDIVIDUALS

(Sections A & B)

Amount of Contribution

Legislative

Date Received
_

Yes

Yes

(Total on Line 13 of Summary Page)

$30.00
$6,454.00
$6,454.00

Page 13 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

C1. Contributions from Other Committees


Name of Treasurer

Name of Committee

Committee for Sensible Gov

Chris W. Tymniak

Address

Is this contribution associated with an


event reported in Section L1?

543 Old Mill Rd .

Yes

No

Amount of Contribution

If yes, list Event #

City

Fairfield

State

Zip Code

Date Received

CT

06824

08/12/2015

Aggregate Contributions

$250.00

Total of Section C1

$250.00

$250.00

I. MONETARY RECEIPTS (Section A-K)


TYPE OF REPORT

NAME OF COMMITTEE

October 10 Filing - Original

Ansonia Republican Town Committee


C2. Reimbursements or Surplus Distributions from other Committees
Name of Committee

Name of Treasurer

Address

Date Received

State

City

Zip Code

Amount of Receipt

Payment Type
Reimbursement for shared expense
Surplus Distribution

Expenditure # (if applicable)

Description

Total of Section C2

Page 14 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

D. Loans Received this Period


Name of Lender

Source of Loan:
Bank

Street Address

Date of Receipt
Candidate

City

Individual

Other

State

Zip Code

Is there a cosigner or
Guarantor of this loan?
Yes

Name of Cosigner/Guarantor (if applicable)

No

Amount Received

Street Address

City

State

Zip Code

Total of Section D

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

E. Receipts from Entities other than Individuals or Other Committees (Referendum Committees ONLY)
Name of Entity

Street Address

Date Received

State

City

Zip Code

Amount Received

Aggregate Contributions

Total of Section E

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT
October 10 Filing - Original

Ansonia Republican Town Committee

F. Amount Transferred from Affiliated Business Treasury (Business Entity Committees ONLY)
Date of Receipt

Is this transaction associated with an event


reported in Section L1?

Yes

No

Amount

If yes, list Event #

Total of Section F

Page 15 of 26

I. MONETARY RECEIPTS (Section A-K)


NAME OF COMMITTEE

TYPE OF REPORT
October 10 Filing - Original

Ansonia Republican Town Committee

G. Amount Transferred from Affiliated Labor Union or Other Organization Treasury (Organization Committees ONLY)
Date of Receipt

Amount

Total of Section G

I. MONETARY RECEIPTS (Section A-K)


TYPE OF REPORT

NAME OF COMMITTEE

October 10 Filing - Original

Ansonia Republican Town Committee


H. Personal Funds of the Candidate Received this Period (Candidate Committees ONLY)
Date of Receipt

Method of Payment

Amount

Cash

Personal Check

Credit/Debit Card

Total of Section H

I. Monetary Receipts (Section A-K)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT
October 10 Filing - Original

Ansonia Republican Town Committee


J. Interest from Deposits in Authorized Accounts

Date Received

Name of Institution

Street Address

City

State

Amount

Zip Code

Total of Section J

Page 16 of 26

I. MONETARY RECEIPTS (Section A-K)


TYPE OF REPORT

NAME OF COMMITTEE

October 10 Filing - Original

Ansonia Republican Town Committee


K. Miscellaneous Monetary Receipts not Considered Contributions
Name

Date of Transaction

Pumpkin Festival

09/20/2015

Street Address

City

State

Zip Code

French Memorial Park

Seymour

CT

06483

Amount
Received

Description

Annual Festival Fundraiser

$2,496.00
$2,496.00

Total of Section K

II. EVENT ACTIVITY (Sections L1 - L5)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

L1. Event Information


Event #
Date of Event

Letter

Description

Was this a fundraising event?


Yes

Location: Street Address

City

Subpart 1: (All Committees)


Was this event hosted at a personal residence?

Yes
No

Did this fundraiser include goods or services donated by a business entity of


up to $200 or items donated by an individual of up to $100?

Yes

State

No
Zip Code

(If yes, go to Section L5 In-Kind Donations not Considered


Contributions Associated with a House Party and complete required
information for any puchases made by host(s) for food, beverage and
invitations.)

(If yes, go to Section L 4 In-Kind Donations not Considered


Contributions and complete required information.)

No
Was this fundraiser a tag sale, auction, or other sale of donated items with
puchases from an individual of up to $100?

Yes

(If yes, enter Total Receipts here.)

No
Subpart 2: (Party Committees, Municipal Candidates and Political Committees other than Exploratory Committees)
Were there purchases of advertising space in a program book or on a sign associated
with this fundraiser?

Yes

(If yes, go to Section L 3 Purchases of Advertising Space in a Program


Book or on a Sign and complete required information.)

No

Subpart 3: (Town Committees ONLY)


Did your committee sell food or beverage at a fair or similar mass gathering held
within the state with this fundraiser?

Yes

(If yes, enter Total Receipts here.)

No

Total of Section L1

Page 17 of 26

II. EVENT ACTIVITY (Sections L1 - L5)


TYPE OF REPORT

NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

October 10 Filing - Original

Ansonia Republican Town Committee


L3. Purchases of Advertising in a Program Book or on a Sign
Name of Purchaser

Purchase Made By:


Business Entity

Other

Individual/Sole Proprietorship
Street Address

Date Received

City

Event #

Aggregate Purchases for All Events

Zip Code

State

Amount of Program Ad Purchase

Amount of Sign Purchase

Total of Section L3

II. EVENT ACTIVITY (Sections L1 - L5)


TYPE OF REPORT

NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

October 10 Filing - Original

Ansonia Republican Town Committee


L4. In-Kind Donations Not Considered Contributions
Name of the Donor

City

Street Address

Donation Given by:

State

Description of Donation

Fair Market Value of


Donation

Business Entity
Individual

Date Received

Zip Code

Event #

Aggregate value for this event

Sole Proprietorship

Total of Section L4

Page 18 of 26

II.EVENT ACTIVITY (Sections L1 - L5)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT
October 10 Filing - Original

Ansonia Republican Town Committee

L5. In-Kind Donations Not Considered Contributions Associated with a House Party
Is this event supporting more than one candidate or committee?

Name of the Host

Yes

No

If yes, complete Itemization in


Addendum L5

City

Street Address

State

Description of Donation

Zip Code

Fair Market Value of


Donation

Event #

Aggregate value of this Event - all hosts

Aggregate value of all Events - this host/candidate

Total of Section L5

III. NONMONETARY RECEIPTS (Sections M - O)


TYPE OF REPORT

NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

October 10 Filing - Original

Ansonia Republican Town Committee


M. In-Kind Contributions
Name

City

Street Address

Type of Contributor:

Committee

Individual / Sole Proprietorship


Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?

Is this contribution associated with an


event reported in Section L1?
If yes, list Event#

Date Received

Aggregate contributions

State

Zip Code

Description of In-Kind Contribution

Other
Yes
No

If contribution is in excess of $400 to a candidate committee for a chief


executive officer of a municipality does contributor or business he/she is
associated with have a contract with said municipality valued at more
than $5000?
Yes
No

Yes
No

Is contributor a principal of state contractor or prospective state contractor?


If yes, indicate which branch or branches of
government the contract is with:

Fair Market Value of this


Contribution

Yes
No

Executive

Legislative

Total of Section M

Page 19 of 26

III. Non Monetary Receipts (Sections M - O)


NAME OF COMMITTEE

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

N. Refundable Deposit to Telephone Company


Last Name of Individual

Residential Street Address

First Name

City

MI

State

Date Deposit Made

Zip Code

Name of Telephone company

Street Address

City

State

Zip Code

Total of Section N

Amount of
Deposit

Page 20 of 26

IV. EXPENDITURES (Sections P - T)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT
October 10 Filing - Original

Ansonia Republican Town Committee


P. Expenses Paid By Committee
Name of Payee

Date of Payment

EverReady Press

09/03/2015

Street Address

City

Clifton Ave

Ansonia

Purpose of Expenditure
(by code)

Expenditure #
(if applicable)

Check #

Debit Card

174

State

EFT

Zip Code

CT

Description

A-SIGN

Method of Payment

06401
Amount

Event #

Lawn signs

Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)

$6,604.34

None of the below

Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization

Name of Payee

Date of Payment

Naugatuck Valley Health

09/11/2015

Street Address

City

98 Bank St

Seymour

Purpose of Expenditure
(by code)

Expenditure #
(if applicable)

D
Method of Payment
X

Check #

Debit Card

175

State

EFT

06483

Event #

Food Permit

Zip Code

CT

Description

FNDR *

Amount

09202015H

Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)

$65.00

None of the below

Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization

Name of Payee

Date of Payment

Lorie Vaccaro

09/23/2015

Street Address

City

515 Beaver St

Ansonia

Purpose of Expenditure
(by code)

D
Method of Payment
X

Check #

Debit Card

State

CT
Event #

Description

FNDR *

Food

176
_

EFT

Zip Code

06401
Amount

09202015H

Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)

Expenditure #
(if applicable)
X

$783.25

None of the below

Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization

Page 21 of 26

IV. EXPENDITURES (Sections P - T)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT
October 10 Filing - Original

Ansonia Republican Town Committee


P. Expenses Paid By Committee
Name of Payee

Date of Payment

The Hartford

09/23/2015

Street Address

City

1 Hartford Plz

Hartford

Purpose of Expenditure
(by code)

Expenditure #
(if applicable)

Check #

Debit Card

178

State

EFT

Zip Code

CT

Description

Misc *

Method of Payment

06155
Amount

Event #

Committee general liability insurance policy

Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)

$425.00

None of the below

Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization

Name of Payee

Date of Payment

Kirk Products

09/24/2015

Street Address

City

1 Rimmon St

Seymour

Purpose of Expenditure
(by code)

Expenditure #
(if applicable)

D
Method of Payment
X

Check #

Debit Card

181

State

EFT

06483

Event #

Rental Fire Extinguisher

Zip Code

CT

Description

FNDR *

Amount

09202015H

Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)

$30.00

None of the below

Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization

Name of Payee

Date of Payment

Ever Ready Press

09/24/2015

Street Address

City

Clifton Av

Ansonia

Purpose of Expenditure
(by code)

D
Method of Payment
X

Check #

Debit Card

State

CT
Event #

Description

A-SIGN

179
_

EFT

Zip Code

06401
Amount

Palm cards

Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)

Expenditure #
(if applicable)
X

$2,956.51

None of the below

Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization

Page 22 of 26

IV. EXPENDITURES (Sections P - T)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT
October 10 Filing - Original

Ansonia Republican Town Committee


P. Expenses Paid By Committee
Name of Payee

Date of Payment

Ever Ready Press

09/24/2015

Street Address

City

Clifton Av

Ansonia

Purpose of Expenditure
(by code)

Expenditure #
(if applicable)

Check #

Debit Card

180
_

State

EFT

Zip Code

CT

Description

A-SIGN

Method of Payment

06401
Amount

Event #

Signs 2nd Ward

Type of Expenditure ( Itemization in Addendum P Required unless "None of the below" is checked)

$116.99

None of the below

Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization

$10,981.09

Total of Section P

IV. EXPENDITURES (Sections P - T)


TYPE OF REPORT

NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

October 10 Filing - Original

Q. Campaign Expenses Paid By Candidate


Name of Payee (Name of vendor, Person or Entity who candidate paid directly)

Date of Payment

Is Reimbursement Claimed?
Yes

Purpose of Expenditure
(by code)

State

City

Street Address

Description

Event #

No

Zip Code

Amount

Total of Section Q

Page 23 of 26

IV. EXPENDITURES
TYPE OF REPORT

NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

October 10 Filing - Original

Ansonia Republican Town Committee


R. Expenses Incurred on Committee Credit Card
Type of Credit Card:

Name of Issuing Institution

Visa

Master Card

American Express

Discover

Other
Date of Transaction

Name of Vendor, Person or Entity

City

Street Address

Purpose of Expenditure
(by code)

Expenditure #
(if applicable)

State

Description

Zip Code

Event #

Amount

Type of Expenditure ( Itemization in Addendum R Required unless "None of the below" is checked)

None of the below


Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization

Total of Section R

IV. EXPENDITURES
NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

S. Expenses Incurred By Committee but Not Paid During this Period


Date Incurred

Name of Creditor

City

Street Address

Purpose of Expenditure
(by code)

Expenditure#
(if applicable)

Description

State

Amount Incurred
(Estimate or Actual)

Event #

Type of Expenditure (Itemization in Addendum S Required unless "None of the below" is checked)

None of the below


Coordinated with reimbursement sought (joint expenditure)

Independent

Coordinated without reimbursement sought (in-kind contribution

Organization :

Zip Code

Total of Section S

Page 24 of 26

IV. EXPENDITURES (Sections P - T)


NAME OF COMMITTEE (Provide Complete Name as Registered with Filing Repository)

TYPE OF REPORT

Ansonia Republican Town Committee

October 10 Filing - Original

T. Itemization of Reimbursements and Secondary Payees


Last Name of Worker/Consultant

First

MI

Date of Payment to Vendor, Person or Entity

Payment to Reimburse Committee Worker/Consultant as reported in Section P

Name of Vendor, Person or Entity Paid by Committee Worker/Consultant

Check #
Street Address of Vendor, Person or Entity Paid by Committee Worker/Consultant

Purpose of Expenditure
(by code)

Expenditure #

Debit Card

City

State

Event #

Description

None of the below


Independent

Coordinated without reimbursement sought (in-kind contribution)

Organization:

Total of Section T

Section L5. ADDENDUM


NAME OF COMMITTEE

TYPE OF REPORT

L5. In - Kind Donations Not Considered Contribution Associated with a House Party - Addendum

Event #
Name of Candidate or Committee

Zip Code

Amount

Type of Expenditure ( Itemization in Addendem T Required unless "None of the below" is checked)

Coordinated with reimbursement sought (joint expenditure)

EFT

Page 25 of 26

Section P. ADDENDUM
TYPE OF REPORT

NAME OF COMMITTEE

P. Expenses Paid By Committee - Addendum


Expenditure #

Name of Candidate or Committee

Supported

Amount of Expenditure

Opposed

Office Sought (if applicable)

Cost Allocated to Candidate or Committee

Section R. ADDENDUM
NAME OF COMMITTEE

TYPE OF REPORT

R. Expenses Incurred on Committee Credit Card - Addendum


Expenditure #

Name of Candidate or Committee

Supported

Amount of Expenditure

Opposed

Office Sought (if applicable)

Cost Allocated to Candidate or Committee

Section S. ADDENDUM
TYPE OF REPORT

NAME OF COMMITTEE

S. Expenses Incurred by Committee but Not Paid During this Period - Addendum
Expenditure #

Name of Candidate or Committee

Supported

Opposed

Office Sought (if applicable)

Amount of Expenditure

Cost Allocated to Candidate or Committee

Page 26 of 26

Section T. ADDENDUM
TYPE OF REPORT

NAME OF COMMITTEE

T. Itemization of Reimbursements and Secondary Payees - Addendum


Expenditure #

Name of Candidate or Committee

Supported

Opposed

Office Sought (if applicable)

Amount of Expenditure

Cost Allocated to Candidate or Committee