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SEEC FORM 20
Itemized Campaign Finance Disclosure Statement
Rev. 1/08
Office Use OnlyCONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION
Electronic Filing
Page 1 of 40
SUMMARY PAGE
1. NAME OF COMMITTEE
2. TREASURER NAME
Ansonia Republican Town Committee
3. TREASURER ADDRESS
4. ELECTION DATE
7. CANDIDATE NAME
8. TYPE OF REPORT
9. PERIOD COVERED
10. CERTIFICATION
5. OFFICE SOUGHT (if applicable) 6. DISTRICT CODE (if applicable)
Title
Title
First
First
MI
MI
Last
Last
Suffix
Suffix
Street Address City State Zip Code
Jennifer Jones
145 Platt St Ansonia CT 06401
October 10 Filing - Original
Beginning Date Ending Date
07/01/2011 thru 09/30/2011
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.
PRINT NAME OF THE SIGNER DATE CERTIFIED
10/04/2011 4:02:53 pm
PENALTY FOR FALSE STATEMENT IS PUNISHABLE BY FINE NOT TO EXCEED $1,000,
OR IMPRISONMENT FOR NOT MORE THAN ONE YEAR, OR BOTH.
SIGNATURE
Electronic Filing Jennifer Jones
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Page 2 of 40
SUMMARY PAGE
SEEC FORM 20Itemized Campaign Finance Disclosure Statement
CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION
Rev. 1/08
TOTALS
NAME OF COMMITTEE FILING DUE DATE
COLUMN A
This Period
COLUMN B
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
12. Balance on hand at the beginning of Reporting Period
13. Contributions received from Individuals (Section A and B)
14. Receipts from Other Committees (Sections C1 + C2)
15. Other Monetary Receipts (Section D-K)
16c. Total Purchases of Advertising in a Program Book (Section L3)
18. Subtotals (add totals in line 12 + line 17 in Column A and in line 11 + 17 in Column B)
19. Expenses Paid by Committee (Section P)
16b. Total Proceeds from Small purchases at Tag Sales, Auctions or Other Sales (Section L2)
20. Balance on hand at close of Reporting Period (Subtract line 19 from line 18)
21. In-Kind Donations not Considered Contributions Received (Section L4)
22. In-Kind Contributions Received (Section M)
23. Refundable Deposit to Telephone Company (Section N)
24. Receipts of Organization Expenditures (Section O)
25. Beginning Loan Balance
25a. + Loans Received (Section D)
25b. + Interest and Penalties on Loan(s)
25c. - Payments on Loan(s)
25d. Total Outstanding Loan Amount
26. Campaign Expenses Paid By Candidate (Section Q)
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)
$3,115.90
$4,053.53
$1,438.00 $3,538.00
$0.00 $0.00
$0.00 $0.00
16a. Total Small Food and Beverage Receipts at Fair (Section L1)
17. Total Monetary Receipts (add totals for lines 13-16c)
$2,098.00 $2,098.00
$0.00 $0.00
$0.00 $0.00
$3,536.00 $5,636.00
$2,238.94 $3,401.31
$0.00 $0.00
$929.53 $929.53
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00
$0.00
$7,589.53 $8,751.90
Ansonia Republican Town Committee Original 10/11/2011
$5,350.59 $5,350.59
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Page 3 of 40
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
A. Total Contributions from Small Contributors-Received this Period ONLY
(See instructions for definition of Small Contributor) Subtotal Section $0.00
B. Itemized Contributions from Individuals
First Name MI
John
Residential Street Address
6 S Cliff St
City
Ansonia
State Zip Code
CT 06401
Date Received
07/07/2011
Principal Occupation
Name of Employer
Is this contribution associated with afundraising event listed in Section L1?
Yes
NoIf yes, list Event #
Tinley, Nastri, Renehan & Dost, LLP
Lawyer
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
P
Aggregate Contribution
$128.00
Amount of
Contribution
$8.00
Last Name
Marini
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
_
X
First Name MI
Charles
Residential Street Address
23 Granite Ter
City
Ansonia
State Zip Code
CT 06401
Date Received
07/14/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Self Employed/Great Northern Excavating
Excavating Contractor
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
W
Aggregate Contribution
$425.00
Amount of
Contribution
$25.00
Last Name
Stowe
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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 acontract with said municipality valued at more than $5000?
_
Yes
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Joan
Residential Street Address
198 Wakelee Ave
City
Ansonia
State Zip Code
CT 06401
Date Received
07/14/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Lear Pharmacey
Pharmacist
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
P
Aggregate Contribution
$300.00
Amount of
Contribution
$75.00
Last Name
Radin
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
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Page 4 of 40
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
B. Itemized Contributions from Individuals
First Name MI
Warner
Residential Street Address
162 Center Rd
City
Woodbridge
State Zip Code
CT 06525
Date Received
07/21/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Philips Healthcare Informatics
Sales Manager
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
C
Aggregate Contribution
$25.00
Amount of
Contribution
$25.00
Last Name
Pyne
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Philip
Residential Street Address
27 Eagle St
City
Ansonia
State Zip Code
CT 06401
Date Received
07/24/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Home Depot
Sales
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$25.00
Amount of
Contribution
$25.00
Last Name
Tripp
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_
Executive Legislative
_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
David
Residential Street Address
3 High Acres Rd
City
Ansonia
State Zip Code
CT 06401-2951
Date Received
07/26/2011
Principal Occupation
Name of Employer
Is this contribution associated with afundraising event listed in Section L1?
Yes
No07312011aIf yes, list Event #
Birmingham Management
Owner
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
S
Aggregate Contribution
$485.00
Amount of
Contribution
$60.00
Last Name
Cassetti
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
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Page 5 of 40
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
B. Itemized Contributions from Individuals
First Name MI
William
Residential Street Address
85 Pulaski Hwy
City
Ansonia
State Zip Code
CT 06401
Date Received
07/28/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Naugatuck Valley Savings and Loan
Vice President
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
C
Aggregate Contribution
$250.00
Amount of
Contribution
$250.00
Last Name
Nimons
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Irving
Residential Street Address
14 Highland Ave
City
Ansonia
State Zip Code
CT 06401-2518
Date Received
07/28/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Materials Testing Inc.
Quality Control Manager
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
F
Aggregate Contribution
$135.00
Amount of
Contribution
$30.00
Last Name
Reed
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_
Executive Legislative
_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
John
Residential Street Address
11 Hawley Dr
City
Ansonia
State Zip Code
CT 06401
Date Received
07/30/2011
Principal Occupation
Name of Employer
Is this contribution associated with afundraising event listed in Section L1?
Yes
No07312011aIf yes, list Event #
Tinley, Nastri, Renehan & Dost, LLP
Lawyer
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
P
Aggregate Contribution
$168.00
Amount of
Contribution
$40.00
Last Name
Marini
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
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Page 6 of 40
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
B. Itemized Contributions from Individuals
First Name MI
Cheryl
Residential Street Address
16 Harris Rd
City
Ansonia
State Zip Code
CT 06401
Date Received
07/31/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Sinclair Insurance Group Inc.
Commercial Account
Executive
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$25.00
Amount of
Contribution
$25.00
Last Name
Henri
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Randolph
Residential Street Address
40 Fourth St # 10
City
Ansonia
State Zip Code
CT 06401
Date Received
07/31/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Unknown
Unknown
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$55.00
Amount of
Contribution
$15.00
Last Name
Carroll
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_
Executive Legislative
_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Edward
Residential Street Address
51 Grove St
City
Ansonia
State Zip Code
CT 06401
Date Received
07/31/2011
Principal Occupation
Name of Employer
Is this contribution associated with afundraising event listed in Section L1?
Yes
No07312011aIf yes, list Event #
Qwest Communications Inc..
Sr Sales Engineer
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$15.00
Amount of
Contribution
$15.00
Last Name
Norman
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
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Page 7 of 40
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
B. Itemized Contributions from Individuals
First Name MI
Patricia
Residential Street Address
28 W Brookside Ave
City
Ansonia
State Zip Code
CT 06401
Date Received
07/31/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
State of CT- Dept. of Childrens and Families
Paralegal Specialist II
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
J
Aggregate Contribution
$150.00
Amount of
Contribution
$20.00
Last Name
Fers
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Nancy
Residential Street Address
18 Farrel Dr
City
Ansonia
State Zip Code
CT 06401
Date Received
08/04/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No07312011aIf yes, list Event #
Yules and Yules LLC
Legal Assistant
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$200.00
Amount of
Contribution
$100.00
Last Name
Valentine
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_
Executive Legislative
_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Charles
Residential Street Address
23 Granite Ter
City
Ansonia
State Zip Code
CT 06401
Date Received
09/01/2011
Principal Occupation
Name of Employer
Is this contribution associated with afundraising event listed in Section L1?
Yes
NoIf yes, list Event #
Self Employed/Great Northern Excavating
Excavating Contractor
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
W
Aggregate Contribution
$485.00
Amount of
Contribution
$60.00
Last Name
Stowe
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
_
X
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Page 8 of 40
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
B. Itemized Contributions from Individuals
First Name MI
Nancy
Residential Street Address
18 Farrel Dr
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No09292011AIf yes, list Event #
Yules and Yules LLC
Legal Assistant
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$380.00
Amount of
Contribution
$180.00
Last Name
Valentine
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Irving
Residential Street Address
14 Highland Ave
City
Ansonia
State Zip Code
CT 06401-2518
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No09292011AIf yes, list Event #
Materials Testing Inc.
Quality Control Manager
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
F
Aggregate Contribution
$235.00
Amount of
Contribution
$100.00
Last Name
Reed
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_
Executive Legislative
_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Deirdre
Residential Street Address
23 Granite Ter
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with afundraising event listed in Section L1?
Yes
No09292011AIf yes, list Event #
Yale
Business analyst
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
M
Aggregate Contribution
$60.00
Amount of
Contribution
$60.00
Last Name
Stowe
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
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Page 9 of 40
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
B. Itemized Contributions from Individuals
First Name MI
Patricia
Residential Street Address
28 W Brookside Ave
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No09292011AIf yes, list Event #
State of CT- Dept. of Childrens and Families
Paralegal Specialist II
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
J
Aggregate Contribution
$175.00
Amount of
Contribution
$25.00
Last Name
Fers
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Richard
Residential Street Address
13 Murray St
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No09292011AIf yes, list Event #
Retired
Retired
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
S
Aggregate Contribution
$20.00
Amount of
Contribution
$20.00
Last Name
Bruchal
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_
Executive Legislative
_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Joan
Residential Street Address
198 Wakelee Ave
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with afundraising event listed in Section L1?
Yes
No09292011AIf yes, list Event #
Lear Pharmacey
Pharmacist
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
P
Aggregate Contribution
$458.88
Amount of
Contribution
$40.00
Last Name
Radin
_ Cash _ Money OrderX Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
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I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
B. Itemized Contributions from Individuals
First Name MI
David
Residential Street Address
3 High Acres Rd
City
Ansonia
State Zip Code
CT 06401-2951
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No09292011AIf yes, list Event #
Birmingham Management
Owner
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
S
Aggregate Contribution
$585.00
Amount of
Contribution
$100.00
Last Name
Cassetti
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Philip
Residential Street Address
27 Eagle St
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No09292011AIf yes, list Event #
Home Depot
Sales
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$85.00
Amount of
Contribution
$60.00
Last Name
Tripp
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_
Executive Legislative
_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
Vincent
Residential Street Address
199 Pulaski Hwy
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with afundraising event listed in Section L1?
Yes
No09292011AIf yes, list Event #
Self-Employed
Cabinet Maker
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$40.00
Amount of
Contribution
$40.00
Last Name
Scarlata
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
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I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
B. Itemized Contributions from Individuals
First Name MI
Randolph
Residential Street Address
40 Fourth St # 10
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No09292011AIf yes, list Event #
Retired
Retired
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
Aggregate Contribution
$75.00
Amount of
Contribution
$20.00
Last Name
Carroll
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_ Executive Legislative_
_ Payroll Deduction
Method of Contribution
X
_
First Name MI
John
Residential Street Address
11 Hawley Dr
City
Ansonia
State Zip Code
CT 06401
Date Received
09/29/2011
Principal Occupation
Name of Employer
Is this contribution associated with a
fundraising event listed in Section L1?Yes
No09292011AIf yes, list Event #
Tinley, Nastri, Renehan & Dost, LLP
Lawyer
Is contributor a lobbyist, spouse,
or dependent child of a lobbyist?
P
Aggregate Contribution
$188.00
Amount of
Contribution
$20.00
Last Name
Marini
X Cash _ Money Order_ Personal Check Credit/Debit Card_
Yes_
NoX
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
X
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:
_
Yes No
_
_
Executive Legislative
_
_ Payroll Deduction
Method of Contribution
X
_
TOTAL OF ALL CONTRIBUTIONS FROM INDIVIDUALS (Sections A & B) (Total on Line 14 of Summary Page)
Total of Section B $1,438.00
$1,438.00
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I. MONETARY RECEIPTS (Section A-I)
NAME OF COMMITTEE
Ansonia Republican Town Committee
FILING DUE DATE
C1. Contributions from Other Committees
Original 10/11/2011
ame of Committee Name of Treasurer
ddress
City State
Is this contribution associated with a
fundraising event listed in Section L1?
Yes
No
If yes, list Event #
Zip Code Date Received Aggregate Contributions
Amount of Contribution
Total of Section C1
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C2. Reimbursements. Payments. or Surplus Distributions from other Committees
NAME OF COMMITTEE
Ansonia Republican Town Committee
FILING DUE DATE
I. MONETARY RECEIPTS (Section A-I)
Original 10/11/2011
me of Committee Name of Treasurer
Address
City State Zip Code
Date ReceivedAmount of Receipt
Reimbursement for shared expense
Payment for goods and services
Surplus Distribution
Total of Section C2
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E. Receipts from Entities other than Individuals or Other Committees (Referendum Committees ONLY)
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Original 10/11/2011Ansonia Republican Town Committee
Street Address
City State Zip Code
Amount
Received
Name
Date Received
Aggregate Contributions
Total of Section E
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F. Amount Transferred from Affiliated Business Treasury (Business Entity Committees ONLY)
I. MONETARY RECEIPTS (Section A-I)
NAME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
AmountDate of ReceiptIs this transaction associated with a fundraising event listed in Section L1?
Yes No If yes, list Event #
Total of Section F
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G. Amount Transferred from Affiliated Labor Union or Other Organization Treasury (Organization Committees ONLY)
I. MONETARY RECEIPTS (Section A-I)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
AmountDate of Receipt
Total of Section G
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H. Personal Funds of the Candidate Received this Period (Candidate Committees ONLY)
I. MONETARY RECEIPTS (Section A-K)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Amount Method of PaymentDate Received
Cash Personal Check Credit/Debit Card
Total of Section H
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I. Anonymous Contributions
I. MONETARY RECEIPTS (Section A-K)
NAME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Amountcoins$ 10 bill$ 5 bills$ 1 billsDate Received
Total of Section I
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J. Interest from Deposits in Authorized Accounts
I. Monetary Receipts (Section A-I)
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Zip CodeStateCityStreet Address
Date ReceivedName of Institution Amount
Received
Total of Section J
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K. Miscellaneous Monetary Receipts not Considered Contributions
I. MONETARY RECEIPTS (Section A-K)
NAME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address Cit State Zip Code
Description
Amount
Received
Name Date of Transaction
Total of Section K
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L1. Fundraiser Event Information
II. FUNDRAISING EVENT ACTIVITY
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Zip Code
LetterDate of Fundraiser
Fundraising Event # Location: Street Address City State
07/31/2011 a 18 Farrell Dr Ansonia CT 06401
Was this fundraising event hosted at a personal residence?
Did this fundraiser include items donated by a business entity of up to $100 or items donated by an
individual of u to $50?
Was this fundraiser a tag sale, auction, or other sale of donated items?
X _Yes No
Yes
Yes
No
No
X _
_ X
Picnic Event
Description
Were there purchases of advertising space in a program book associated with this is fundraiser?
Did your committee sell food or beverage at a fair or similar mass gathering held within the state?
Yes
Yes
No
No
_ X
_ X
Subpart 2: (Town Committees and Municipal Candidate Committees ONLY)
Subpart 3: (Town Committees ONLY)
If yes, enterTotal Receipts $0.00
If yes, go to Section L4
If yes, go to Section L4
If yes, go to Section L2
If yes, go to Section L3
from small purchases
Subpart 1: (All Committees)
Zip Code
LetterDate of Fundraiser
Fundraising Event # Location: Street Address City State
09/18/2011 A French Memorial Park Seymour CT 06483
Was this fundraising event hosted at a personal residence?
Did this fundraiser include items donated by a business entity of up to $100 or items donated by an
individual of u to $50?
Was this fundraiser a tag sale, auction, or other sale of donated items?
_ XYes No
Yes
Yes
No
No
X _
_ X
Fair Event
Description
Were there purchases of advertising space in a program book associated with this is fundraiser?
Did your committee sell food or beverage at a fair or similar mass gathering held within the state?
Yes
Yes
No
No
_ X
X _
Subpart 2: (Town Committees and Municipal Candidate Committees ONLY)
Subpart 3: (Town Committees ONLY)
If yes, enterTotal Receipts $2,098.00
If yes, go to Section L4
If yes, go to Section L4
If yes, go to Section L2
If yes, go to Section L3
from small purchases
Subpart 1: (All Committees)
Zip Code
LetterDate of Fundraiser
Fundraising Event # Location: Street Address City State
09/29/2011 A 70 Main St Ansonia CT 06401
Was this fundraising event hosted at a personal residence?
Did this fundraiser include items donated by a business entity of up to $100 or items donated by an
individual of u to $50?
Was this fundraiser a tag sale, auction, or other sale of donated items?
_ XYes No
Yes
Yes
No
No
_ X
_ X
Dinner Event
Description
Were there purchases of advertising space in a program book associated with this is fundraiser?
Did your committee sell food or beverage at a fair or similar mass gathering held within the state?
Yes
Yes
No
No
_ X
_ X
Subpart 2: (Town Committees and Municipal Candidate Committees ONLY)
Subpart 3: (Town Committees ONLY)
If yes, enterTotal Receipts $0.00
If yes, go to Section L4
If yes, go to Section L4
If yes, go to Section L2
If yes, go to Section L3
from small purchases
Subpart 1: (All Committees)
Total of Section L1 $2,098.00
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L2. Proceeds from Tag Sale, Auction, or Other Sale of Donated Items
II. FUNDRAISING EVENT ACTIVITY
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Zip CodeStateCityResidential Street Address
Method of payment:e of the Purchaser Aggregate
Amount of
PurchasesLast Name
First Name MI
Event #
Items Purchased
Personal CheckCash Credit/Debit Card
Date Received
(Individuals ONLY)
Total of Section L2
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L3. Purchases of Advertising in a Program Book(Municipal Candidate and Town Committees ONLY)
II. FUNDRAISING EVENT ACTIVITY
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Zip CodeStateCityStreet Address
Business EntityName of Purchaser Amount of
PurchaseEvent # Date Received
Aggregate Purchases
NoYes
for All Events
for All Events
Total of Section L3
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L4. In-Kind Donations Not Considered Contributions
II. FUNDRAISING EVENT ACTIVITY
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Zip CodeStateCityStreet Address
Donation given by:Name of the Donor Fair Market
Value of
Donation
Aggregate value for this event
Description of Donation Date Received Event #
Individual Business E ntity
Total of Section L4
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M. In-Kind Contributions
III. NONMONETARY RECEIPTS
NAME OF COMMITTEE
Ansonia Republican Town Committee Original 10/11/2011
FILING DUE DATE
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Cassetti David
07/14/2011
3 High Acres Rd Ansonia
CT 06401
x
_
07312011a
_
x
60 pre-printed tickets for fundraiser
$15.00 $15.00
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Valentine Nancy
07/31/2011
18 Farrel Dr Ansonia
CT 06401
x
_
07312011a
_
x
use of home for picnic fundraiser
$100.00 $25.00
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
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M. In-Kind Contributions
III. NONMONETARY RECEIPTS
NAME OF COMMITTEE
Ansonia Republican Town Committee Original 10/11/2011
FILING DUE DATE
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Radin P Joan
07/31/2011
198 Wakelee Ave Ansonia
CT 06401
x
_
07312011a
_
x
food and beverages for picnic fundraiser
$349.29 $49.29
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Valentine Nancy
07/31/2011
18 Farrel Dr Ansonia
CT 06401
x
_
07312011a
_
x
plates, napkins, condiments and
plasticware $100.00 $10.00
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
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M. In-Kind Contributions
III. NONMONETARY RECEIPTS
NAME OF COMMITTEE
Ansonia Republican Town Committee Original 10/11/2011
FILING DUE DATE
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Radin Kathy
09/18/2011
214 Roosevelt Dr Seymour
CT 06483
x
_
09182011A
_
x
Hamburgers, buns and onions
$706.29 $637.89
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Radin P Joan
09/18/2011
198 Wakelee Ave Ansonia
CT 06401
x
_
09182011A
_
x
ice for coolers
$418.88 $39.59
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
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M. In-Kind Contributions
III. NONMONETARY RECEIPTS
NAME OF COMMITTEE
Ansonia Republican Town Committee Original 10/11/2011
FILING DUE DATE
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Radin P Joan
09/18/2011
198 Wakelee Ave Ansonia
CT 06401
x
_
09182011A
_
x
fire extinguisher rental
$418.88 $30.00
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Radin Kathy
09/18/2011
214 Roosevelt Dr Seymour
CT 06483
x
_
09182011A
_
x
bottled water
$706.29 $68.40
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
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M. In-Kind Contributions
III. NONMONETARY RECEIPTS
NAME OF COMMITTEE
Ansonia Republican Town Committee Original 10/11/2011
FILING DUE DATE
Street Address
Type of Contributor: Fair Market
Value of this
Contribution
Name
City
State Zip Code
Date Received
Individual
Committee
Is Contributor a lobbyist, spouse, or
dependent child of a lobbyist?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
Yes
No
Is this contribution associated with a fundraising event
listed in Section J1?
If yes, list Event#
Yes
No
Description of In-Kind ContributionAggregate contributions
Diotalev Gene
09/18/2011
51 D Wedgewood Rd Stratford
CT 06614
x
_
09182011A
_
x
cheese for burgers
$54.36 $54.36
_
x
Other
Is contributor a principal of state contractor or prospective state contractor?Yes
No
X
_
_
_
Total of Section M $929.53
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N. Refundable Deposit to Telephone Company
III. NONMONETARY RECEIPTS
ME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Zip CodeStateCityResidential Street Address
Date ReceivedLast Name (Individuals Only) Amount of
Deposit
Name of Telephone company
Zip CodeStateCityStreet Address
First Name MI
Total of Section N
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O. Non-Monetary Receipts of Organization Expenditures Made By
Legislative Leadership, Legislative Caucus, and Party Committee
III. NONMONETARY RECEIPTS
NAME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address Date Notice Received
Description of Donation
Fair Market
Value of
Donation
Name of Committee
City State
Name of Treasurer
Aggregate DonationsZip Code
Purpose of Expenditure
A B C D E
Total of Section O
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P. Expenses Paid By Committee
IV. EXPENDITURES
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Ansonia Rotary: Harvest Festival Committee
PO Box 575 Ansonia CT 06401Misc *
Booth Fee for the Harvest Festival
$50.00
X
_
000107/08/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
(if applicable)
b code
Expenditure
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Seymour Pumpkin Festival
PO Box 860 Seymour CT 06483FNDR
09182011ABooth Fee for the Seymour Pumpkin Festival on 9.18.11
$175.00
X
_
000207/14/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sou ht
Coordinated without reimbursement sought
Independent
Or anization see Instructions
(if applicable)
b code
Expenditure
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
American Heart Association
PO Box 417005 Boston MA 02241CHAR
Charitable donation in memory of a member's father
$50.00
X
_
000307/27/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
(if applicable)
b code
Expenditure
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P. Expenses Paid By Committee
IV. EXPENDITURES
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Naugatuck Valley Health District
98 Bank St Seymour CT 06483FNDR
09182011ATemporary food permit fee for Seymour Pumpkin Festival Booth
$50.00
X
_
000408/04/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sou ht
Coordinated without reimbursement sou ht
Independent
Or anization see Instructions
(if applicable)
b code
Expenditure
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Nancy Valentine
18 Farrel Dr Ansonia CT 06401RCW
07312011aReimbursement for food and ice for picnic fundraiser on 7.31.11
$62.09
X
_
000508/05/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
(if applicable)
b code
Expenditure
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
The Hartford
Hartford Plaza Hartford CT 06115OVHD
Yealry insurance premium
$425.00
X
_
electronic09/01/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
(if applicable)
b code
Expenditure
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P. Expenses Paid By Committee
IV. EXPENDITURES
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Ansonia Commons, LLC
14 Davis Rd Woodbridge CT 06525OVHD
cost of having a Republican Headquarters for three months
$1,000.00
X
_
000609/01/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sou ht
Coordinated without reimbursement sou ht
Independent
Or anization see Instructions
(if applicable)
b code
Expenditure
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Ansonia Rotary/ Harvest Festival
PO Box 575 Ansonia CT 06401A-OTH
Having a booth at the Harvest Festival- not a fundraiser
$50.00
X
_
000709/12/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
(if applicable)
b code
Expenditure
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Massimino's Pizzeria
70 Main St Ansonia CT 06401FOOD
09292011APizza and soda for fundraising event
$264.50
X
_
001009/29/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
(if applicable)
b code
Expenditure
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P. Expenses Paid By Committee
IV. EXPENDITURES
AME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Joan Radin
198 Wakelee Ave Ansonia CT 06401FNDR
09182011ASoda for Pumpkin Festival
$64.58
X
_
000809/30/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sou ht
Coordinated without reimbursement sou ht
Independent
Or anization see Instructions
(if applicable)
b code
Expenditure
Street Address City State Zip Code
Description
Amountame of Payee Date of Payment Method of Payment
Pur ose of
Check #
Debit Card
Event #
Candidate(s) Name Office Sought
Kathy Radin
214 Roosevelt Dr Seymour CT 06483FNDR
09182011ADecorations for the booth
$47.77
X
_
000909/30/2011
Type of Expenditure (if applicable)
_
_
_
_
_ _A B _ C _ D _ E
_
_
Supported
OpposedCoordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
(if applicable)
b code
Expenditure
Total of Section P $2,238.94
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Q. Campaign Expenses Paid By Candidate
IV. EXPENDITURES
NAME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address City State Zip Code
Description
AmountName of Payee (Name of Vendor who candidate paid directly) Date of PaymentIs Reimbursement
Claimed?
Event #
Purpose of
Expenditure (by code)
Yes No
Total of Section Q
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R. Expenses Incurred on Committee Credit Card
IV. EXPENDITURES
NAME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address City State Zip Code
Name of Vendor Amount
Name of Issuing Institution
Date of Transaction
Event #
Type of Credit Card:
Purpose of Expenditure (by code)
Description
Visa Master Card Discover American Express
Other
Total of Section R
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S. Expenses Incurred By Committee but Not Paid During this Period
IV. EXPENDITURES
NAME OF COMMITTEE FILING DUE DATE
Ansonia Republican Town Committee Original 10/11/2011
Street Address City State Zip Code
Description
Name of Creditor Date Incurred Amount Incurred
(Estimate or
Actual)
Purpose of
Expenditure (by
code
Event #
Candidate(s) Name (if applicable) Office SoughtType of Expenditure (if applicable)
A B C D E
Supported
OpposedCoordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
Total of Section S
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Page 40 of 40
IV. EXPENDITURES
AME OF COMMITTEE FILING DUE DATE
Ansonia Re ublican Town Committee Original 10/11/2011
T. Itemization of Reimbursements to Committee Workers and Consultants
Street Address City State Zip Code
Secondary Payee
AmountName of Worker/Consultant Date of Payment Method of Payment
Purpose of Expenditure
Check #
Debit Card
Other Candidate(s) Name Office Sought
Description
Supported
Opposed
Type of Expenditure (if applicable)
Coordinated with reimbursement sought
Coordinated without reimbursement sought
Independent
Organization (see Instructions)
A B C D E
Total of Section T
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