Treasurers Reports
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beachl FL 33436
OFFICE USE ONLY
"
(4)
City, State, Zip Code
D CHECK IF ADDRESS HAS CHANGED
Check appropriate box(es):
[2] Candidate (office sought):
D Political Committee
D Committee of Continuous Existence
D Party Executive Committee
o Electioneering Communication
<=>
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o
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(3)
10 Number:
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Boynton Beach Mayor
D CHECK IF PC HAS DISBANDED
D CHECK IF CCE HAS DISBANDED
D CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
Cover period:
(5) REPORT IDENTIFIERS
From 07 I 01 I 09 To 09 I 30 I 09
Report Type
6;3 ~
-\t4--
~ Original
D Amendment
D Special Election Report
D Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT
(7)
EXPENDITURES THIS REPORT
Cash & Checks
$
Monetary
Expenditures
$
62.69
Loans
$
200.00
Total Monetary
$
200.00
Transfers to Office
Account $
Total
Monetary
$
62.69
In-Kind
$
(8) Other Distributions
$
(9) TOTAL Monetary Contributions To Date
$ 200.00
(10) TOTAL Monetary Expenditures To Date
$ 62.69
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.)
I certify that I have examined this report and it is true, I certify that I have examined this report and it is true,
correct, and complete. correct, and complete.
l-~
C. PTY &
nization)
Cynthia Diane Pereira
. !ZlTreasurer 0 Deputy Treasurer
) )
/'"
DS.DE 12 (Rev. 08104)
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) 1.0. Number
(3) Cover Period
07
I 01
I 09
through
09 I
30
I
09
(4) Page
1
of
1
(5) (7) (8) (9) (10) (11) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number Citv, State, Zio Code Tvoe Occuoation Tvoe Descriotion Amendment Amount
Carl McKoy I unemp10y LOA 200.00
09 , 09 ,09 69 Citrus Park LN
Boynton Beach FL
33436
01
1 1
1 1
1 1
1 1
1 1
1 1
1 1
OS-DE 13 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(1) Name
CAMPAIGN TREASURER'S REPORT -ITEMIZED EXPENDITURES
Carl McKoy (2) I.D. Number
(3) Cover Period ~/~~ through -'!!-.-!~~
(4) Page
1
of
1
(5) (7) (8) (9) (10) (11)
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought If
Sequence Street Address & contribution to a Expenditure
Number City, State, Zip Code candidate) Type Amendment Amount
09 /16 /09 Bank Atlantic Checks MON $62.69
100 N Congress Ave
Boynton Beach, FL 33426
1
/ /
/ /
/ /
/ /
/ /
/ /
/ /
OS-DE 14 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beach, FL 33436
City, State, Zip Code
o CHECK IF ADDRESS HAS CHANGED
OFFICE USE ONLY
.. of the CIty Clerk
;,,-- \ - \\ - \ a ;:\ ~
~:\5~
(3) 10 Number:
(4) Check appropriate box(es):
[ZJ Candidate (office sought): Boynton Beach Mayor
o Political Committee 0 CHECK IF PC HAS DISBANDED
o Committee of Continuous Existence 0 CHECK IF CCE HAS DISBANDED
o Party Executive Committee
o Electioneering Communication 0 CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Cover Period: From 10 / 01 / 09 To 12 / 31 / 09 Report Type Ql
-- ---
[ll Original 0 Amendment 0 Special Election Report 0 Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT
Monetary
Cash & Checks $ 400.26"- Expenditures $ 398.20
Loans $ Transfers to Office
Account $
Total Monetary $ Total
Monetary $ 398.20..(
In-Kind $ 100.00
(8) Other Distributions
$
(9)
TOTAL Monetary Contributions To Date
$ f?JO. 600 6Vo~
(10)
TOTAL Monetary Expenditures To Date
$ 'ft;.Srf, 432.02./
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (55. 839.13, F .S.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true,
correct, and com plete. correct, and com plete.
(Type name) Cynthia Diane Pereira
Dlndividual (on for Treasurer D Deputy Treasurer
electioneering m/ un.
X/"
Signature
OS-DE 12 (Rev. 08/04)
~~-'-_.
y for PC,J~J,( &
un. organization)
?--~
....?
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) 1.0. Number
10
01
12
31
09
1
(3) Cover Period / / 09 through / / (4) Page of 1
(5) (7) (8) (9) (10) (11 ) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number City, State, Zio Code Tvoe Occuoation Tvoe Descriotion Amendment Amount
Dr. G. W. Mingo I CAS 100.00
12 I 01 109 P.O. Box 13119
Gainesville, FL
32604
1
12 I 03 p9 Shirley Mingo I Retired CHE 300.00
311 Olivia St.
Key West, FL
33040
2
Gifts, Gadgets & B INK Banner 100.00
12 / 02 Op Giveaways
211 S.W. Lake
Circle Dr.
3 Boynton Bch FL 334
JJ-I 15 / /17 /~..." /~ ( 13 CIlf" . :J <:>
"'j.j( .A/, /~r 1r I~t(
L( .I~..,~.re CA
"~/J / fJt;,.,/
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S 1'-~ -;jet:. t~ fJ~1
<j;IJI
/ I
/ /
/ /
OS-DE 13 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
Carl McKoy (2) J.D. Number
(3) Cover Period ~/~/~ through ~/~/~
(4) Page
1
of
1
(5) (7) (8) (9) (10) (11)
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
12 /03 /09 Short Run Printing solutions Magnet Signs MON $53.25
14545J Military Trail #227
Delray Beach,FL 33484
1
Short Run Printing Solutions Palm Cards MON $244.95
12 /03 j09 14545J Military Trail #227
Delray Beach,FL 33484
2
Asset Foundry, Inc. Web Page Work MON $100.00
12 /23 /09 6329 Lantana Pines Circle
Lantana FL, 33462
3
/ /
/ /
/ /
/ /
/ /
OS-DE 14 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
OFFICE USE ONLY
Offtce of tit. City ClerIc
(i / /.;).O/ID /. ~ <) ;::'/Lt-
Boynton Beach FL 33436
City, State, Zip Code
o CHECK IF ADDRESS HAS CHANGED (3) 10 Number:
(4) Check appropriate box(es):
[ZJ Candidate (office sought): Boynton Beach Mayor
o Political Committee 0 CHECK IF PC HAS DISBANDED
o Committee of Continuous Existence 0 CHECK IF CCE HAS DISBANDED
o Party Executive Com mittee
o Electioneering Communication 0 CHECK IF NO OTHER ELECTIONEERING
COMMUNICA TION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Cover Period: From 10 / 1 / 09 To 12 / 31 / 09 Report Type Q1
-- --
o Original [ZJ Amendment 0 Special Election Report 0 Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT
(7)
EXPENDITURES THIS REPORT
~'f.6,~. ~ f Monetary
Cash & Checks $ 'It"OO. ~ Expenditures $
Loans $ Transfers to Office
Account $
Total Monetary $ Total
Monetary $
In-Kind $ 100.00
432.02
432.02
(8) Other Distributions
$
(9) TOTAL Monetary Contributions To Date (10)
$ 662 .1Il. ~
TOTAL Monetary Expenditures To Date
$ ff. t'f~Olrr 119eL 91
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (55. 839.13. F .S.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true.
correct, and com plete. correct, and com prete.
(Type name) Cynthia Diane Pereira
D'ndividual (only for 0 Deputy Treasurer
electioneering com un)
x
OS-DE 12 (Rev. 08/04)
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) 1.0. Number
10
1
09
12
31
09
1
1
(3) Cover Period I / through / / (4) Page of
(5) (7) (8) (9) (10) (11 ) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number Citv, State, Zio Code Tvoe Occuoation Tvoe Descriotion Amendment Amount
Bank Atlantic B REF ADD 62.69
10 / 15 109 100 N.Congress ave for
Boynton Beach, FL checks
33426 not
1 receiv
Dr. G.W. Mingo .\ I CAS 100.00
12 I 1 p9 P.O. Box 13119
Gainsville FL
33040
2
Gifts , gadgets & B INK Banner 100.00
12 I 02 Of Giveaways
211 S.W. Lake
Circle Dr.
3 Boynton Bch FL 334
12 I Shirly Mingo I Retired CHE 300.00
03 /09 311 Olivia St.
Key West, FL
33040
4
/ /
I /
/ /
I /
OS-DE 13 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
0fI0t of .. CItV CI-
O//Ol0/IO '.0 ~~ P/v'\
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
Carl McKoy (2) I.D. Number
(3) Cover Period __~./~/~ through ~/~/~
(4) Page
1
of
1
(5) (7) (8) (9) (10) (11)
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
10 /07 /09 Bank Atlantic Checks for MON ADD $33.82
100 N. Congress Ave. campaign had to
Boynton Beach, FL 33426 account reorde
b r
checks
Short Run Printing Solutions Palm Cards MON $244.95
12 /03 /09 14545J Military Trail #227
Delray Beach, FL 33484
~
....
Short Run Printing Solutions Magnet Signs MON $53.25
12 /03 /09 14545J Military Trail #227
Oelray Beach, FL 33484
8'
Asset Foundry, Inc Web Site Work MON $100.00
12 /23/09 6329 Lantana Pines Circle
Lnatana, FL 33462
9
/ /
/ /
/ /
/ /
OS-DE 14 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
,1~~' ,1tit, t; ~~;'.' .' }...~I;!(
~~~;'.~~.t ;~I : ~" ~"I.~~"Ptv\
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beach FL 33436
City, State, Zip Code
o CHECK IF ADDRESS HAS CHANGED
OFFICE USE ONLY
_eflte City Clerk
~. \ - ~&. ~a\c:> ~
~'.o~~
~.
(3) 10 Number:
(4) Check appropriate box(es):
!Zl Candidate (office sought): Boynton Beach Mayor
D Political Committee D CHECK IF PC HAS DISBANDED
D Committee of Continuous Existence 0 CHECK IF CCE HAS DISBANDED
D Party Executive Com mittee
o Electioneering Communication 0 CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Cover Period: From 01 I 01 I 10 To 01 I 21 I 10 Report Type E1
-- ---
[lI Original 0 Amendment 0 Special Election Report 0 Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT
(7)
EXPENDITURES THIS REPORT
c~
3(j(), 716 ~
$
Cash & Checks $
Monetary
600 . 00 / Expenditures
Loans
$
Total Monetary
$
600.00
Transfers to Office
Account $
Total
Monetary
$
L~J~
3 ~Ci ' <is' c\ 3-4 5 . eo
In-Kind
$
(8) Other Distributions
$
(9)
TOTAL Monetary Contributions To Date
$ I, 262 . 697
(10)
TOT AL ~onetary Expenditures To Date/
$ "'~ 'ltJ~(jf~.
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true.
correct, and com plete. correct, and com pJete.
(Type name) Cynthia Diane Pereira
Dlndividual (only for Treasurer 0 Deputy Treasurer
electioneering com n.)
x
OS-DE 12 (Rev. 08/04)
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
Carl McKoy (2) 1.0. Number
(3) Cover Period _~_L_~_:_/~ through ~/~~
(4) Page
1
of
1
(5) (7) (8) (9) (10) (11)
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
01 120 110 Short Run Printing Solutions Palm Cards MON $340.80
14545J Military Trail #227
Delray Beach FL 33484
1
&- rC-~~ r ~.lr"j&1''t /404 r~~l (~J""1. /10 AI 1.1 tJ ,eX
cJ( Iff I (0 :; e .--(It r. , L (. /4 &
jJ <!) ,;:"10 'Y 7)j -Z..ll ~ q A u VGt...- e b "'-
~ IJe1~"~ /..?<-t.... ~.L
3 3' 'I '7 &/
/ I
I I
I I
I I
/ /
I I
OS-DE 14 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) 1.0. Number
01
01
01
21
10
1
(3) Cover Period I I 10 through I I (4) Page of 101
(5) (7) (8) (9) (10) (11 ) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number City, State, Zip Code Type Occupation Type Descriotion Amendment Amount
SUAU Enterprise B Gas CHE 300.00
01 / 11 110 2380 N.Federal HWY Station
Boynton Beach FL
33436
1
;0 Boynton Carolina B Restaur CHE 100.00
01 I 12 Ale House ant
365 N. Congress
Boynton Beach FL
2 33426
Lance Chaney I CAS 100.00
01 / 18 1p 4312 Pomelo Blvd.
Boynton Beach FL
33436
3
01 / Marilane Chaney I CAS 100.00
18 110 4312 Pomelo Blvd.
Boynton Beach FL
33436
4
/ 1
/ 1
/ 1
1 1
OS-DE 13 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beach, FL 33436
City, State, Zip Code
o CHECK IF ADDRESS HAS CHANGED
OFFICE USE ONLY
(3) 10 Number:
,"')
- ,,-
Q ---I
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-<0
(")'"'TJ
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(4) Check appropriate box(es):
[Z] Candidate (office sought): Boynton Beach Mayor
o Political Committee 0 CHECK IF PC HAS DISBANDED
o Committee of Continuous Existence 0 CHECK IF CCE HAS DISBANDED
o Party Executive Committee
o Electioneering Communication 0 CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Cover Period: From 01 / 22 / 10 To 02 / 04 / 10 Report Type E2
-- ---
[lI Original 0 Amendment 0 Special Election Report 0 Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT
Monetary
Cash & Checks $ 820.00 Expenditures $ 372.72
Loans $ Transfers to Office
Account $
Total Monetary $ 820.00 Total
Monetary $ 372.72
In-Kind $ .500.00
(8) Other Distributions
$
(9) TOTAL Monetary Contributions To Date
$ /:tfrJ. ({, 7
(10) TOTAL Monetary Expenditures To Date
$ 1,214.41
(11 ) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (55. 839.13, F.S.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true,
correct, and com plete. correct, and com plete.
X //
"-..Q.. .t.-J<.--"'-'
~-
(Type name) Cynthia Diana Pereira
Dlndividual (only for o Treasurer 0 Deputy Treasurer
electioneering mu.) <:'
Signature
OS-DE 12 (Rev. 08/04)
(5) (7) (8) (9) (10) (11 ) or ~~
Date FuJI Name :r:
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number City, State, Zio Code Tvoe Occuoation Tvoe Descriotion Amendment Amount
Dr.& Mrs. E.M. I CHE 40.00
01 / 25 ,10 Harris
6885 Country Fair
Cir.
1 Boynton Beach FL
33437 a
10 Vernon Blake I CHE 70.00
01 / 24 P.O. Box 243794
Boynton Beach FL
33424
2
Andrew I CHE 100.00
01 / 27 Ip Degraffenreidt
508 cypress Drive
Lake Park FL 33403
3
Madeline Tucker I CAS 50.00
01 I 29 ,10 137 N.W. 14th Ave.
Delray Beach FL
33444
4
N. Harrison I CAS 10.00
01 I 30 , 10 3535 Danbury Court
Boynton Beach FL
33436
5
01 30 to Karen Mingo I CAS 50.00
I 1624 N.E. First
St.
Boynton Beach FL
6 33435
01 29 10 Richard Tullie PA B CHE 500.00
I 6971 N. Federal Attorney
HWY Suite 401
Boca Raton FL
7 33487
Carl McKoy I Busines INK Campaign ---. " " "
01 I 26 to 69 Citrus Park s/volun 5~O...U(: I-
LN. Signs
Boynton Beach FL teer
33436 -~
'-' L-
8 I-
/
10
through
02
04
(4) Page
-
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CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) 1.0. Number
(3) Cover Period
01
22
/
10
1
OS-DE 13 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
Carl McKoy (2) I.D. Number
(3) Cover Period ~/~~ through ~/~~
(4) Page
1
of
1
(5) (7) (8) (9) (10) (11 )
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
01 /22 /10 Palm Beach County Supervisor Walking List MON $38.00
of Elections
240 South Military Trail
1 West Palm beach FL 33415
Palm Beach County Supervisor Petition MON $3.90
01 /25 /10 of Elections Verification
240 South Military Trail
West Palm beach FL 33415
2
Palm Beach County Supervisor CD MON $30.00
01 /26 /10 of Elections
240 South Military Trail
West Palm beach FL 33415
3
City of Boynton Beach City Filing MON $25.00
02/01/10 100 East Boynton Beach Blvd. Fee
Boynton Beach FL 33435
4
City of Boynton Beach State MON $275.82
02 /01 /10 100 East Boynton Beach Blvd. Assessment
Boynton Beach FL 33435 Filing Fee
5
/ /
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.;
OS-DE 14 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
FLORIDA ~EPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beach, FL 33436
City, State, Zip Code
D CHECK IF ADDRESS HAS CHANGED
Check appropriate box(es):
D Candidate (office sought):
D Political Committee
D Committee of Continuous Existence
D Party Executive Com mittee
D Electioneering Communication
OFFICE USE ONLY
(3) ID Number:
(4)
Boynton Beach Mayor
D CHECK IF PC HAS DISBANDED
D CHECK IF CCE HAS DISBANDED
D CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Cover Period: From 01 /22 /10 To 02 /04 /10 Report Type E2
--- ---
D Original !]I Amendment D Special Election Report D Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT
(7)
EXPENDITURES THIS REPORT
/ Monetary
Cash & Checks $ 820.00 Expenditures $ 372.72
Loans $ Transfers to Office
Account $
Total Monetary $ 820.00 ,/ Total
Monetary $ 372_72
In-Kind $ 500.00 /
/
.I
(8) Other Distributions
$
(9) TOTAL Monetary Contributions To Date
$ 2,082.95 ./
(10) TOTAL Monetary Expenditures To Date
$ 1248.23
(11 ) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (55. 839.13, F .5.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true,
correct, and com plete. correct, and com plete.
(Type name)
Dlndividual ~only fo
electioneerin mm
Treasurer 0 Deputy Treasurer
x
Signature
OS-DE 12 (Rev. 08/04)
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beach, FL 33436
City, State, Zip Code
o CHECK IF ADDRESS HAS CHANGED
OFFICE USE ONLY
(3) ID Number:
(4)
Check appropriate box(es):
[Z] Candidate (office sought): Boynton Beach Mayor
o Political Committee 0 CHECK IF PC HAS DISBANDED
o Committee of Continuous Existence 0 CHECK IF CCE HAS DISBANDED
o Party Executive Com mittee
o Electioneering Communication
-"
c::>
."
o CHECK IF NO OTHER ELECTIONEERING g
COMMUNICATION REPORTS WILL BE FILEIN
[lI Original
o Amendment
o Special Election Report
'-J
("') -4
=i-<
-<0
("")..."
ICD
fTlo
Cover Period:
(5) REPORT IDENTIFIERS
From 02 / 05 / 1 0 To 02 / 18 / 10
Report Type
.."
m
(6) CONTRIBUTIONS THIS REPORT
(7)
EXPENDITURES THIS REPORT
:r:
Monetary
Cash & Checks $ 1,280.00/ Expenditures $
Loans $ Transfers to Office
Account $
Total Monetary $ ~ 02otJ,o tJ Total
Monetary $
In-Kind $
(8) Other Distributions
$
tfg-(Qr7~ ./
~'li~(b~~ ./
(9)
(10) TOTAL Monetary Expenditures To Date
$ 1!.;5/,,}_)
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (55. 839.13, F .S.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true,
correct, and com plete. correct, and com plete.
TOTAL Monetary Contributions To Da~
$ 3_3~;2 i 5_~ v-'
x
x
(Type name) Cynthia Diane Pereira
Dlndividual (only for 0 Deputy Treasurer
electioneering com _)
Signature
OS-DE 12 (Rev. 08/04)
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) I.D. Number
02
05
10
02
18
10
1
1
(3) Cover Period / / through / / (4) Page of
(5) (7) (8) (9) (10) (11 ) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number City, State, Zip Code Type Occupation Type Description Amendment Amount
Janice Hepburn I CHE 10.00
02 / 05 /10 461 SW 4th Ave.
Boynton Beach FL
33435
1
Bernice Steinman I CHE 100.00
02 / 05 ?-O 11231 Wingfoot Dr.
Boynton Beach FL
33437
2
Hester Butler I CHE 50.00
02 / 05 1p 411 NE 15th Court
Boynton Beach FL
33435
3
Ocean Ridge B chiropr CRE 500.00
02 / 05 /10 Chiropractic Ctr. actor
212 E. Boynton
Beach blvd.
4 Boynton Bch. FL 33
Barbara Butler I Educato CHE 500.00
02 / 06 / 10 411 NE 15th Court r
Boynton Beach FL
33435
5
02 07 to Stanley Gomez I CAS 20.00
/ 811 SW 1st Ave
boynton Beach FL
33426
6
02 09 ?-O Doc's Reality Co. B CHE 100.00
/ 1901 S. Federal
Rwy
boynton beach Fl
7 33436
/ /
OS-DE 13 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
Carl McKoy (2) 1.0. Number
(3) Cover Period ~~~ through ~~~
(4) Page
1
of
1
(5) (7) (8) (9) (10) (11)
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
02 /09 /10 Short Run Printing Palm Cards MON $340.80
14545J Military Trail #227
Delray Beach, FL 33464
1
Sign Depot Yard Signs MON $346.12
02 /18 /10 1813 E. Colonial Dr.
Orlando, FL 32803
2
/ /
/ /
/ /
/ /
/ /
/ /
OS-DE 14 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beach FL 33436
City, State, Zip Code
o CHECK IF ADDRESS HAS CHANGED
OFFICE USE ONLY
(3) ID Number:
C)
--a. n-i
0 =i-<
:x -<0
x- C"")"
:::;0
, .eD
mo
co ::0-<
:;,;:
::r: (/)0
O;z::
(N V1
.. "eD
- ,."
~l>
("')
:x
(4)
Check appropriate box(es):
[Z] Candidate (office sought): Boynton Beach Mayor
o Political Committee 0 CHECK IF PC HAS DISBANDED
o Committee of Conti nuous Existence 0 CHECK IF CCE HAS DISBANDED
o Party Executive Com mittee
o Electioneering Communication
o CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
Cover Period:
(5) REPORT IDENTIFIERS
From 02 / 19 / 10 To 03 / 04 / 10
Report Type
E4
[ZI Original
o Amendment
o Special Election Report
o Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT
(7)
EXPENDITURES THIS REPORT
J 7'15.00 Monetary ~17 D~
Cash & Checks $ .I Expenditures $ ,/
Loans $ Transfers to Office
Account $
Total Monetary $ ~ 745. OD .I Total J-~97 () ~
Monetary $ /
In-Kind $
(8) Other Distributions
$
(9)
TOTAL Mon,*a7 Contrib~ns To Date
$ (p 07 tt- /
(10)
TOTAL Monetary Expenditures To D}lte
$ %d-g ?::i v'
(11 ) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (55. 839.13, F.S.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true,
correct, and com plete. correct, and com plete.
x
(
..--
(Type name) Cynthia Diane Pereira
o Individual (only for 0 Deputy Treasurer
electioneering commu
Signature
OS-DE 12 (Rev. 08/04)
Si
//---\,-_.c-------
~/ .--
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) I.D. Number
02
19
10
03
04
10
3
3
(3) Cover Period / / through / / (4) Paae of
(5) (7) (8) (9) (10) (11 ) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number Citv, State, Zio Code Tvoe Occuoation Tvoe Descriotion Amendment Amount
Sandra Raymond I CHE 50.00
03 / 02 /10 52 Citrus park
Lane Boynton Beach
FL 33436
17
03 04 ?-O Bernice Steinman I CHE 50.00
/ 11231 Wingfoot Dr.
Boynton Beach FL
33437
18
Phyllis Greisdorf I CHE 10.00
03 / 04 Ip 7224 Summer Tree
Drive
Boynton Beach FL
19 33437
Paulette Berdick I CAS 20.00
03 / 04 /10 P.O. Box 220871
West Palm Beach FL
33422
20
Addie Greene I CHE 50.00
03 / 04 / 10 1617 Boardman Ave.
Mangonia Park FL
33407
21
03 04 10 Guarim Simms I Educato CHE 150.00
/ Boynton Beach FL r
22
02 27 ?-O United Haitian B Activist CHE 150.00
/ American s
10657 Greenbriar
Ct.
23 Boca Raton FL33498
Marla Billing I CAS 75.00
03 / 04 ?-O 3778 Sandpiper Dr.
Boynton Beach FL , , :C ~d 8- tlVU 0
33436
24 3:11.:1.:10 '~'.~~J13 All.
". tl' ..1{] -llr
OS-DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS ANU \,vue VAt. ~S
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) I.D. Number
02
10
03
04
10
19
2
3
(3) Cover Period / / through / / (4) Paae of
(5) (7) (8) (9) (10) (11 ) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number City, State, Zip Code Tyoe Occupation Tvoe Descriotion Amendment Amount
Catherine Hinson I CHE 30.00
02 / 27 110 413 NW 5th Ave.
Boynton Beach FL
33435
9 ,
27 ?-O Angela Smith I CHE 15.00
02 / 1291 SW 27th PL
Boynton Beach FL
33426
10
Cheryl Skinner I CHE 25.00
02 1 28 1p 711 NW 1st. St. ,
Boynton Beach FL
33435
11
02 / Janice Hepburn I CHE 25.00
28 110 461 W 4th Ave.
Boynton Beach Fl
33435
12
,
Sergio Casaine I CHE 100.00
02 / 28 1 10 13 Meadows Park
Lane
Boynton Beach FL
13 33436
02 28 10 Karen Mingo I retired CHE 400.00
/ 1624 NE 1st. St.
Boynton Beach FL ,
33435
14
02 27 ?-O Nathan Smith I CHE 50.00
1 10939A Roebelini
Palm ct.
Boynton Beach FL
15 33437
Anton Elwood I Pastor ,
CHE 465.00
02 / 28 ?-O 3308 Quantum Lakes
Dr.
Boynton Beach FL I I :C Wd
16 33426 B ~VW 0 l
OS-DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIOn~6E~il&sA 118
DINAO "';
a .:10 AJI"
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) I.D. Number
02
19
03
04
10
(3) Cover Period / / 10 through / / (4) Paae of
(5) (7) (8) (9) (10) (11 ) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number Citv, State, Zio Code Tvoe Occuoation Tvpe Descriotion Amendment Amount
William Ashbury I CHE 50.00
02 / 19 110 268 Kate Lane
Warren Robins GA
31088
1
?-O Alisabeth Salogar I CHE 100.00
02 1 19 653 SW 4th Ave.
Boynton Beach FL
33426
2
Cynthia Pereira I CHE 50.00
02 / 19 1p 7692 Colony Lake
Dr.
Boynton Beach FL
3 33436
Prime Plaza Inc B CHE 250.00
02 / 21 /10 65 Spanish River
Dr.
Boynton Beach FL
4 33435
SEIU CHE 500.00
02 1 21 / 10 7001 Lake Elanor
Dr.
Orlando FL 32809
5
02 22 fO Joan Guyette I CHE 30.00
/ 504 SW 7th St.
Boynton Beach FL
33426
6
02 22 ?-O Christine Ruffin I CHE 50.00
/ 504 SW 7th St
Boynton Beach FL
33426
7
E. Baker I CHE 40.00
02 / 26 ?-O 550 NW 9th Ave.
Boynton Beach FL
33435 II :C Wd B - ~VW Ol
8
....". I ,., ,1\ .-......... . ,.....
<J. "....... ,\.1 f'\... .IV
OS-DE 13 (Rev. 08(03)
SEE REVERSE FOR INSTJH!P1~~~'1IR~9BE~W~r:!)
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
Carl McKoy
(2) I.D. Number
02
19
10
03
04
10
4
4
(3) Cover Period / / through / / (4) Page of
(5) (7) (8) (9) (10) (11 ) (12)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number Citv, State, Zio Code Tvoe Occuoation Tvoe Descriotion Amendment Amount
Billy Brown I CAS 30.00
03 1 04 110 P.O. Box 4114
Boynton beach FL
33424
25
1 1
1 1
/ 1
1 1
1 1
1 1
1 1
I I :& Wd B ~ ~VW 0 L
r..'H,J,Jn ~."').I 'I 1 I J')
OS-DE 13 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONeWiiS~eESO All J
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
Carl McKoy (2) I.D. Number
(3) Cover Period ~~~ through ~/~~
(4) Page
1
of
2
(5) (7) (8) (9) (10) (11 )
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
02 fI9 /10 Sign Depot Campaign Signs MON $346.12
1813 E. Colonial Dr.
Orlando FL 32803
1
USPS Stamps MON $497.20
03 /01 /10 1530 W. Boynton Beach Blvd.
Boynton beach FL 33435
2
Sign Depot Signs MON $346,13
03 /03 /10 1813 E. Colonial Dr.
Orlando FL 32803
3
Shell Gas MON $63.40
03 /03/10 8840 Lawrence Rd.
Boynton Beach FL 33436
4
Office Depot paper MON $38.33
03/04/10 260 N. Congress Ave.
Boynton Beach FL 33426
5
PBC Supervisor of Elections Lables MON $34.00
03 /05 /10 240 S. Military Trail
West Palm Beach FL
6
Office Depot Supplies MON $47.98
03 /05 /10 260 N. Congress Ave.
Boynton Beach FL 33426
7
Office Depot Printer Ink MON $211.90
03 /05/10 260 N. Congress Ave.
Boynton Beach FL 33426
8 Z I :~ ~ d 9- ~~ W O~
OS-DE 14 (Rev. 08/03 331J.:W ~.~H313 ^ ~
If
SEE REVERSE FOR INSTRUCTIONS AND CODE V~~8 NOINA08 .:W ),,110
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
Carl McKoy (2) I.D. Number
(3) Cover Period ~/~/~ through ~/~/~
(4) Page
2
of
2
(5) (7) (8) (9) (10) (11)
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
03 /06 /10 USPS Postage MON $1,012.00
1530 W. Boynton Beach Blvd.
Boynton Beach FL 33435
9
/ /
/ /
/ /
/ /
/ /
/ /
/ / Z' :C Ud
8- HVU L
3JI:J:Jn ~ ' .-
OS-DE 14 (Rev. 08/03 rvV.::J8 .... ..'oJ A1 j~J
SEE REVERSE FOR INSTRUCTIONS AND CODE V ALUE~ 0 1 N ^ 0 a :J 0 ^ 11 J
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beach FL 33436
City, State, Zip Code
o CHECK IF ADDRESS HAS CHANGED
OFFICE USE ONLY
(3) ID Number:
(4) Check appropriate box(es):
[Z] Candidate (office sought): Boynton Beach Mayor
o Political Committee 0 CHECK IF PC HAS DISBANDED
o Committee of Continuous Existence 0 CHECK IF CCE HAS DISBANDED
o Party Executive Committee
o Electioneering Communication 0 CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
Cover Period: From 02 19 I 10 To 03 I 04 I 10 Report Type E4
-- ---
o Original III Amendment 0 Special Election Report 0 Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT
(7)
EXPENDITURES THIS REPORT
~& ~ecks
<=: u ,.. .
w- ,~
mu... ..
L~ M
o (J) ::c
~- Q..
~iM~tary
co~ -
l.\..u >-
ex:
I~d x:
>-- 0
t::u -
C)
Monetary
Expenditures $
2,254.06
$
2,745.00
$
Transfers to Office
Account $
Total
Monetary $
2,254.06'
$
2,745.00
$
(8) Other Distributions
$
(9)
TOTAL Monetary Contributions To Date
$ 6,107.95 vi
(10)
TOTAL Monetary Expenditures To Date ./"
$ 4,189.21 v'
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (55. 839.13, F .S.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true,
correct, and com plete. correct, and com plete.
(Type name) Cynthia Diane Pereira
D Individual (only for Treasurer D Deputy Treasurer
electioneering mun..
(Type name)
ILl Candidate
x
Signa~!,!ra .cc__...
Signature
OS-DE 12 (Rev. 08/04)
-)
-
:I:
::-
-<
0)
"
:x
U1
..
N
R' REPORT - ITEMIZED EXPENDITURES
(1) Name C (2) I.D. Number
(3) Cover Period 02-. /~~ throug ...Q3-I~~ (4) Page 1- of ~
(5) (7) (8) (9) (10) (11 )
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if
Sequence Street Address & contribution to a Expenditure
Number City, State, Zip Code candidate) Type Amendment Amount
~ I to USPS SThMt:>S VloN
IS30 W.~~~ 6l\kt. 1f11~
1 b>~nWn l ti... 3~lfbS
!; Slt ~t Ol5nS HON l3
~ \0 /3l3 E. CD onta\V(IIJe. ~--
l Orlci1do J Fi-
32803
:3 .? S~\ Ga& HON (oo1Q.
to 8f)L\:-O ~{0nC.Q..- ~.
~ ~~(\~/fi- Co
3b 3
cx:ti~ 1X'~ ~~r ,,^ON- 38~
2100 ~. CG~S Ne.
1:D'jn-IDn '-eo. I FL.
~t1o
3 5 ?6C ~. of Becl10fiS ~S VlON 34'~
LO .240~. M'l\l tarj -V~ll
5 tJest- ~lrn ~l fi.
35 ~C~~ 0\Af>p\ l~ MON V 5\tQ
lO 2W N.Co~sSAl
~\)r*on ~b~~ \ ADD"
to
O-tr Lee-. 1X:pJt- ttLnw:In K- MON 2.11 9Q.
lO 2W N. ~'(e]S
.~ ~(f1-- 3~lf26
lASS ~~~ ~oN \ 0 \ t..~
Ire> \~ \N. ~~ ~ ,,\
~~n\ov. ~ \ R.634'~
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
"
(1) Name
(3) Cover Period 0 2 /~~ through
ORT - ITEMIZED EXPENDITURES
(2) 1.0. Number
(4) Page
~
of
~
(5) (7) (8) (9) (10) (11)
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
2./IQ/IO Sl~ fpprf- CaY\~tJ ~l\Cdk. V
l<6l3 S. tDnl~1 --or. 8\<a L.-ls+t~ DEL 340. 12-
q D(landB,Fi 32g03 VlcN
ottce lX-p::>t &fP\l~ '(1.("ror ot V
:] /5/\0 ef)-IU[
2JD N Cort(fes~ N~ HON rDEL 41,98
''fu~vrtDy\ \-Xhl ~
[iC)
~ '3 Lt '2-to
/ /
/ /
/ /
1:)
<; P .. -.
=1-<
/ / -It -<0
-~ n"'"
.1- r- a:J
(10 ,." 0
:::0-<
lrt ;:';::z:
...:~
~ o~
/ / ~ ~a:J
I~ - ,."
n:>
/"T1n
::t:
/ /
OS-DE 14 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Carl McKoy
Name
(2) 69 Citrus Park Lane
Address (number and street)
Boynton Beach FL 33436
City, State, Zip Code
o CHECK IF ADDRESS HAS CHANGED
OFFICE USE ONLY
(3) ID Number:
(4) Check appropriate box(es):
[Z] Candidate (office sought): Boynton Beach Mayor
o Political Committee 0 CHECK IF PC HAS DISBANDED
o Committee of Continuous Existence 0 CHECK IF CCE HAS DISBANDED
o Party Executive Com mittee
o Electioneering Communication 0 CHECK IF NO OTHER ELECTIONEERING
COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS
From 03 I 5 I 1 0 To 06 I 0 7 I 10
Cover Period:
Report Type
TR
[iI Original
o Amendment
o Special Election Report
o Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT
(7)
EXPENDITURES THIS REPORT
Cash & Checks $
:x: $
~s ..:r
wS:? N
co lL. ..
l.\.. M $
~I ~etary
_(J) 0-
z-
>-::s:::
m~ind~ $
l.\..u ~
0>- x:
>-!:: 0
0.00
Monetary
Expenditures
$
1,918.74
0.00
Transfers to Office
Account $
Total
Monetary
$
1,918.74
(8) Other Distributions
$
c.,
(9)
TOTAL Monetary Contributions To Date
$ 6,107.95)
(10)
TOTAL Monetary Expenditures To Date
$ 6,107.95 ~
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (55. 839.13, F.S.)
I certify that I have exam ined this report and it is true, I certify that I have exam ined this report and it is true,
correct, and com plete. correct, and com plete.
(Type name) Cynthia Diane Pereira
Dlndividual (only for ., Treasurer D Deputy Treasurer
electioneering coprnwn.)
X/.-f---~. tG
Signature
OS-DE 12 (Rev. 08/04)
CITY OF BOYNTON BEACH
CAMPAIGN TREASURER'S REPORT - ITEMra:rua..WNlffflJRES
(~) I.D. ~lIplb.er2lJ
10 HAl 18 rn J:
(3) Cover Period _~!.._L.!3~!~ through ~/~/~ (4) Page 1
(1) Name
Carl McKoy
of
1
(5) (7) (8) (9) (10) (11)
Date Full Name Purpose
(6) (Last, Suffix, First, Middle) (add office sought if Expenditure
Sequence Street Address & contribution to a
Number City, State, Zip Code candidate) Type Amendment Amount
03 /25 /10 Metro PCS Phone MON $44.00
Boynton Beach Blvd.
Boynton Beach FL 33436
1
Shell Oil gas MON $62.25
03 /15 /10 Lawerance Road
Boynton Beach FL 33436
2
Walmart #1398 Supplies MON $41.35
03 /10 /10 4545 Hypoluxo Rd.
Lake Worth FL 33463
3
B J Wholesales beverages MON $45.74
03/10/10 1404 W Boynton Beach Blvd.
Boynton Beach, FL 33426
4
B J Wholesales Food MON $194.73
03 /10 /10 1404 W Boynton Beach Blvd.
Boynton Beach, FL 33426
5
Asset Foundry, Inc. website MON $400.00
03 /25 /10 6329 Lantana Pines Cir
Lantana FL, 33462
6
Juvenile Transition Center Non Profit MON $1,130.67
05 /17 /1'0 P.O.Box 244102 Donation
Boynton Beach FL 33424
7
/ /
DS-DE 14 (Rev. 08/03)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES