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Campaign Treasurer's Reports WAIVER OF REPORT (Section 106.07(7), F.S.) (PLEASE TYPE) u —7" yin O UST -ONLY _) r (.; t �� B L S tea, l Name Office Sought 1 ) - 3 \J A A- 130Y PO r 1 3;A36 Address City State Zip Code Candidate ❑ Committee of Continuous ❑ Electioneering Communication Organization Existence ❑ Political Committee ❑ Party Executive Committee C Check box if address has changed since last report ❑ Check here if PC, CCE, or ECO has DISBANDED and will no longer file reports TYPE OF REPORT (Check Appropriate Box) QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION ❑ January ❑ 32nd day prior ❑ 46th day prior ❑ ril ❑ 18th day prior ❑ 32nd day prior July ❑ 4th day prior ❑ 18th day prior ❑ TERMINATION REPORT ❑ October ❑ 4th day prior ❑ SPECIAL ELECTION NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF A p r 1 2 3 11 THROUGH / 2 �0 C � J � ll / l X D Pt6){r� � � ` <) f� l I Signature Date SIGNATURES REQUIRED FOR: Candidates Candidate, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Political Committees Chairman, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Committees of Continuous Existence and Electioneering Communication Organizations Treasurer (s 106 04(4)(c), F S ) Party Executive Committees Treasurer or Chairman (s 106 29(2), F S ) In any reporting period when there has been no activity in the account (no funds expended or received) the filing of the required report is waived However, the filing officer must be notified in writing on the prescribed reporting date that no report is being filed DS -DE 87 (Rev. 07/10) WAIVER OF REPORT Ra,eJet-,��y/0 (Section 106.07(7), F.S.) (PLEASE TYPE) OFFICE USE ONLY Dr Po r 1 I a sS Name Office Sought 11 Ta 8E Fl 343` Address City State Zip Code Candidate ❑ Committee of Continuous ❑ Electioneering Communication Organization Existence n Political Committee ❑ Party Executive Committee ❑ Check box if address has changed since last report ❑ Check here if PC, CCE, or ECO has DISBANDED and will no longer file reports TYPE OF REPORT (Check Appropriate Box) QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION ❑ January ❑ 32nd day prior ❑ 46th day prior ❑ April ❑ 18th day prior ❑ 32nd day prior ❑ July ❑ 4th day prior ❑ 18th day prior ❑ TERMINATION REPORT ❑ October ❑ 4th day prior ❑ SPECIAL ELECTION NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF }tl I? 0 ('I , �ITHROUGH � pf 3 V L 0 11 X D (r !S �C�Ci� l /D -a 4- 206 / Signature Date SIGNATURES REQUIRED FOR: Candidates Candidate, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Political Committees Chairman, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Committees of Continuous Existence and Electioneering Communication Organizations Treasurer (s 106 04(4)(c), F S ) Party Executive Committees Treasurer or Chairman (s 106 29(2), F S ) In any reporting period when there has been no activity in the account (no funds expended or received) the filing of the required report is waived However, the filing officer must be notified in writing on the prescribed reporting date that no report is being filed DS -DE 87 (Rev. 07!10) WAIVER OF REPORT k i; r� ; ` (Section 106.07(7), F.S.) "' ( ,�.E E ACH (PLEASE TYPE) 12 „I/4i 1 ; P 39 OFFICE USE ONLY Piotr Blass Mayor Name Office Sought 113 West Tara Lakes Drive Boynton Beach FL 33436 Address City State Zip Code 2 Candidate ❑ Committee of Continuous ❑ Electioneering Communication Organization Existence ❑ Political Committee ❑ Party Executive Committee ❑ Check box if address has changed since last report ❑ Check here if PC, CCE, or ECO has DISBANDED and will no longer file reports TYPE OF REPORT (Check Appropriate Box) QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION ❑ January ❑ 32nd day prior ❑ 46th day prior ❑ Apnl ❑ 18th day prior ❑ 32nd day prior ❑ July ❑ 4th day prior ❑ 18th day prior ❑ TERMINATION REPORT 121 October ❑ 4th day prior ❑ SPECIAL ELECTION NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF October 1, 2011 THROUGH December 31, 2011 X D Pi zed 2��/ , /01 Signature Date SIGNATURES REQUIRED FOR: Candidates Candidate, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Political Committees Chairman, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Committees of Continuous Existence and Electioneering Communication Organizations Treasurer (s 106 04(4)(c), F S ) Party Executive Committees Treasurer or Chairman (s 106 29(2), F S ) In any reporting period when there has been no activity in the account (no funds expended or received) the filing of the required report is waived However, the filing officer must be notified in writing on the prescribed reporting date that no report is being filed DS -DE 87 (Rev. 07/10) WAIVER OF REPORT (Section 106.07(7), F.S.) (1f i!� (�E? Cl� (PLEASE TYPE) 12 j ' A i` �� i 12: 35 OFFICE USE ONLY Dr. Piotr Blass Mayor at -Large Name Office Sought 113 West Tara Lakes Drive Boynton Beach FL 33436 Address City State Zip Code Candidate ❑ Committee of Continuous ❑ Electioneering Communication Organization Existence E Political Committee ❑ Party Executive Committee E Check box if address has changed since last report ❑ Check here if PC, CCE, or ECO has DISBANDED and will no longer file reports TYPE OF REPORT (Check Appropriate Box) QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION ❑ January ❑ 32nd day pnor ❑ 46th day pnor 121 April ❑ 18th day prior ❑ 32nd day prior ❑ July ❑ 4th day prior ❑ 18th day prior ❑ TERMINATION REPORT ❑ October ❑ 4th day pnor ❑ SPECIAL ELECTION NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF January 1, 2012 THROUGH March 31, 2012 X Dr 13'(J2M 1 I 201C Signature Date SIGNATURES REQUIRED FOR: Candidates Candidate, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Political Committees Chairman, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Committees of Continuous Existence and Electioneering Communication Organizations Treasurer (s 106 04(4)(c), F S ) Party Executive Committees Treasurer or Chairman (s 106 29(2), F S ) In any reporting period when there has been no activity in the account (no funds expended or received) the filing of the required report is waived However, the filing officer must be notified in writing on the prescribed reporting date that no report is being filed DS -DE 87 (Rev. 07/10) WAIVER OF REPORT (Section 106.07(7), F.S.) (PLEASE TYPE) OFFICE USE ONLY Dr. Piotr Blass Mayor Name Office Sought 113 West Tara Lakes Drive Boynton Beach FL 33436 Address City State Zip Code Candidate ❑ Committee of Continuous ❑ Electioneering Communication Organization Existence E Political Committee ❑ Party Executive Committee Check box if address has changed since last report ❑ Check here if PC, CCE, or ECO has DISBANDED and will no longer file reports TYPE OF REPORT (Check Appropriate Box) QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION ❑ January ❑ 32nd day prior ❑ 46th day prior fU ❑ April ❑ 18th day prior ❑ 32nd day prior Ed July ❑ 4th day prior ❑ 18th day prior ❑ TERMINATION R,POR =± ❑ October ❑ 4th day prior 0 SPECIAL ELEC ►u^ N c NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF April 1, 2012 THROUGH June 30, 2012 X f1otr &I AA/ 2. 2. IZ. Signature 0 Date SIGNATURES REQUIRED FOR: Candidates Candidate, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Political Committees Chairman, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Committees of Continuous Existence and Electioneering Communication Organizations Treasurer (s 106 04(4)(c), F S ) Party Executive Committees Treasurer or Chairman (s 106 29(2), F S ) In any reporting period when there has been no activity in the account (no funds expended or received) the filing of the required report is waived However, the filing officer must be notified in writing on the prescribed reporting date that no report is being filed DS -DE 87 (Rev. 07/10) WAIVER OF REPORT v E ACi (Section 106.07(7), F.S.) i c (PLEASE TYPE) a H 26 A:111: 47 OFFICE USE ONLY Piotr Blass Mayor Name Office Sought 113 West Tara Lakes Drive Boynton Beach FL 33436 Address City State Zip Code 2 Candidate ❑ Committee of Continuous ❑ Electioneering Communication Organization Existence ❑ Political Committee ❑ Party Executive Committee Check box if address has changed since last report ❑ Check here if PC, CCE, or ECO has DISBANDED and will no longer file reports TYPE OF REPORT (Check Appropriate Box) QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION ❑ January ❑ 32nd day prior ❑ 46th day prior ❑ April ❑ 18th day prior ❑ 32nd day prior ❑ July ❑ 4th day prior ❑ 18th day prior ❑ TERMINATION REPORT ❑ October ❑ 4th day prior ❑ SPECIAL ELECTION NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF July 1, 2012 THROUGH September 30, 2012 X j g ucs e of 420 Signature b ate SIGNATURES REQUIRED FOR: Candidates Candidate, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Political Committees Chairman, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Committees of Continuous Existence and Electioneering Communication Organizations Treasurer (s 106 04(4)(c), F S ) Party Executive Committees Treasurer or Chairman (s 106 29(2), F S ) In any reporting period when there has been no activity in the account (no funds expended or received) the filing of the required report is waived However, the filing officer must be notified in writing on the prescribed reporting date that no report is being filed / DS -DE 87 (Rev. 07/10) I� ; . LE CC {Q 1 1/I WAIVER OF REPORT s T y „ uEACH (Section 106.07(7), F.S.) 4 ' ; 'TICE (PLEASE TYPE) 13 JAN -8 PM 2: 45 OFFICE USE ONLY D r^ P( 0i In B two �- yk) Name Office Sought 113 UC/-eS 1 LakeA 6Q yvtiUA &( L1 E1 l , 3 13( Address City State / Zip Code C a n didate ❑ C ommittee of Continuous ❑ El ectioneering Communication Organization Existence ❑ Political Committee ❑ Party Executive Committee ❑ Check box if address has changed since last report ❑ Check here if PC, CCE, or ECO has DISBANDED and will no longer file reports TYPE OF REPORT (Check Appropriate Box) QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION ❑ January ❑ 32nd day prior ❑ 46th day prior ❑ April ❑ 18th day prior ❑ 32nd day prior ❑ yy ❑ 4th day prior ❑ 18th day prior ❑ TERMINATION REPORT UP/October ❑ 4th day prior ❑ SPECIAL ELECTION NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF 10/I / THROUGH 1}P,4.. 3 1 ) 2 0 1 x D r-- 6 , M ; 4 k 0 I L Signature , / Date SIGNATURES REQUIRED FOR: Candidates Candidate, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Political Committees Chairman, Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Committees of Continuous Existence and Electioneering Communication Organizations Treasurer (s 106 04(4)(c), F S ) Party Executive Committees Treasurer or Chairman (s 106.29(2), F S ) In any reporting period when there has been no activity in the account (no funds expended or received) the filing of the i required report is waived However, the filing officer must be notified in writing on the prescribed reporting date that no report is being filed DS -DE 87 (Rev. 07/10) WAIVER OF REPORT (Section 106.07(7), F.S.) (PLEASE TYPE) OFFICE USE ONLY Dr. Piotr Blass Mayor - City of Boynton Beach Name Office Sought 113 West Tara Lakes Boynton Beach, FL 33436 Address City State Zip Code © Candidate ❑ Committee of Continuous Existence n Electioneering Communication Organization Political Committee n Party Executive Committee n Check box if address has changed since last report n Check here if PC, CCE, or ECO has DISBANDED and will no longer file reports TYPE OF REPORT (Check Appropriate Box) QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION ❑ January ❑ 32nd day prior 13 46th day prior ❑ April ❑ 18th day prior ❑ 32nd day prior ❑ July ❑ 4th day prior ❑ 18th day prior ❑ TERMINATION REPORT ❑ October ❑ 4th day prior ❑ SPECIAL ELECTION NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF 01 - 01 - 2013 01 - 25 - 13 THROUGH X 1) >~ I ��� � S )/ 6(/ 2 L; ( Signature Date X Signature Date SIGNATURES REQUIRED FOR: Candidates: Candidate and Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Political Committees: Chairman and Campaign Treasurer or Deputy Treasurer (s 106 07(5), F S ) Committees of Continuous Existence and Electioneering Communication Organizations: Treasurer (s 106 04(4)(c), F S ) Party Executive Committees: Treasurer and Chairman (s 106 29(2), F S ) In any reporting period when there has been no activity in the account (no funds expended or received) the filing of the required report is waived However, the filing officer must be notified in wnting on the prescribed reporting date that no report is being filed DS -DE 87 (Rev. 04/13) FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY (1) ' / r Pi 0 f (- 13 la S S OFFICE USE ONLY Name ,� ( ti W. I u-I/ ( I, Address (number and street) City, State, Zip Code w ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: — r (4) C ck appropriate box(es): ,( /� _ 7:,. C andidate (office sought): ''" l� 4- yo 4 = ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED c ; ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED CM r ❑ Party Executive Committee • Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From / / To / / Report Type ❑ Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Vc)j Cash & Checks $ Expenditures $ et; Loans $ 100 ( ) Transfers to Office Account $ 1 Total Monetary $ Total Monetary $ In -Kind $ (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary EZ ggnditures To Date $ 1( $ D( '! (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. (Type name) 3 �i / W WeAl (Typ name) Y El Individual (only for LLA Treasurer ❑ Deputy Treasurer LU/fandidate ❑ Chairperson (only for PC, PTY & electioneenng commun ) electioneering commun organization) X X Signature Signature DS -DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name II I/ GJ zoui (2) l.D. Number (3) Cover Period / / through / / (4) Page of (5) (7) (8) ( ( ( ( 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 2 / 7 / �',� L c.2 a kt 5 w1 L o r vv i. ir f v n C u )) k' PyClUt -1' 4- I / / / / / / / / / / / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name (2) I.D. Number (3) Cover Period / / through / / (4) Page of (5) ( ( ( ( (11) Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought if Street Address & contribution to a Expenditure Sequence City, State, Zip Code candidate) Type Amendment Amount Number 2 /124 ()C.i/w F--& zo 4 E e (1 (J,A. s t'ifytigh4i lot) / / / / / / / / / / / / / / DS -DE 14 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY ( Dr. Piotr Blass OFFICE USE ONLY Name ( 113 W Tara Lakes Address (number and street) Boynton Beach FL 33436 City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: (4) Check appropriate box(es): ❑ Candidate (office sought) Mayor - City of Boynton Beach ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence n CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication E. CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period From 02 / 09 / 2013 To 02 / 22 / 2013 Report Type E -3 2 Original U Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ Expenditures $ Loans $ Transfers to Office Account $ Total Monetary $ Total Monetary $ In -Kind $ (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date (10) TOTAL Moneta Expenditures To Date $ 1U (: pi f '' }fi $ 57 2 (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. (Type name) (Type name) ❑ Individual (only for ❑ Treasurer ❑ Deputy Treasurer ❑ Candidate ❑ Chairperson (only for PC, PTY & electioneenng commun) electoneenng communnorganization) X D 3 L i,' B-'66244 X D Signature Signature DS -DE 12 (Rev. 08/04) INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT SUMMARY (1) Type full name of candidate, political committee, committee of continuous existence, party executive committee, or individual or organization filing an electioneering communication report (2) Type the address (include city, state, and zip code) You may use a post office box If the address has changed since the last report filed, check the appropriate box (3) Type identification number assigned by the Division of Elections. (4) Check one of the appropriate boxes Candidate (type office sought - include district, circuit, or group numbers) Political Committee Committee of Continuous Existence Party Executive Committee Electioneering Communication If PC or CCE has disbanded and will no longer file reports, check appropriate box If individual or organization will no longer file electioneering communication reports, check appropriate box (5) Type the cover period dates (e g , From 07/01/03 To 09/30/03) Enter the report type using one of the following abbreviations (see Calendar of Election and Reporting Dates) If report is for a special election, add "S" in front of the report code (e g , SG3) Quarterly Reports General Election Reports January Quarterly Q4 46 Day Prior G1 April Quarterly Q1 32 " Day Prior G2 July Quarterly Q2 18 Day Prior G3 October Quarterly Q3 4th Day Prior G4 Primary Reports 32 "d Day Prior F1 90 -Day Termination Reports (Candidates Only) 18 Day Prior F2 Termination Report TR 4 th Day Prior F3 Check one of the appropriate boxes Original (first report filed for this reporting period) Amendment (an amendment to a previously filed report) Special Election Report Independent Expenditure Report (see Section 106 071, F S.) (6) Type the amount of all contributions this report Cash & Checks Loans Total Monetary (sum of Cash & Checks and Loans) In -kind (a fair market value must be placed on the contribution at the time it is given) (7) Type the amount of all expenditures this report Monetary Expenditures Transfers to Office Account (elected candidates only) Total Monetary (sum of Monetary Expenditures and Transfers to Office Account) (8) Type the amount of other distributions (goods & services contributed to a candidate or other committee by a PC, CCE or PTY) (9) Type the amount of TOTAL monetary contributions to date (parties keep cumulative totals for 2 year periods at a time (e g , 01/01/02 — 12/31/03) Candidates keep cumulative totals from the time the campaign depository is opened through the termination report) (10) Type the amount of TOTAL monetary expenditures to date (parties keep cumulative totals for 2 year periods at a time (e g , 01/01/02 — 12/31/03) Candidates keep cumulative totals from the time the campaign depository is opened through the termination report) (11) Type or print the required officer's name and have them sign the report Candidate report (treasurer & candidate must sign) PC report (treasurer & chairperson must sign) CCE report (treasurer must sign) PTY report (treasurer & chairperson must sign) Electioneering Communication report (individual or organization's treasurer & chairperson must sign) AMENDMENT REPORTS: An amendment report summary should summarize only contributions, expenditures, distributions, & fund transfers being reported as additions or deletions. Read the instructions for the sequence number & amendment type fields on the back of forms DS -DE 13, 14, 14A and 94. The Division will summarize all reports submitted for each reporting period and for the filer to date. FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY ( Dr. Piotr Blass OFFICE USE ONLY Name ( 113 W Tara Lakes Address (number and street) Boynton Beach FL 33436 City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: (4) Check appropriate box(es): © Candidate (office sought) Mayor - City of Boynton Beach ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication 1 1 CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period From 02 / 23 / 2013 To 03 / 08 / 2013 Report Type E -4 ® Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ Expenditures $ Loans $ Transfers to Office Account $ Total Monetary $ Total Monetary $ In -Kind $ (8) Other Distributions (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ I O ) `" r S � t-t $ S7 i (1 1) 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. (Type name) (Type name) ❑ Individual (only for ❑ Treasurer ❑ Deputy Treasurer ❑ Candidate ❑ Chairperson (only for PC, PTY & electioneenng commun) electioneering commun organization) X 0 r" 1 3 J 4J(' X c f3/ 12A/ Signature Signature DS -DE 12 (Rev. 08/04) INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT SUMMARY (1) Type full name of candidate, political committee, committee of continuous existence, party executive committee, or individual or organization filing an electioneering communication report. (2) Type the address (include city, state, and zip code) You may use a post office box If the address has changed since the last report filed, check the appropriate box (3) Type identification number assigned by the Division of Elections (4) Check one of the appropriate boxes Candidate (type office sought - include district, circuit, or group numbers) Political Committee Committee of Continuous Existence Party Executive Committee Electioneering Communication If PC or CCE has disbanded and will no longer file reports, check appropriate box If individual or organization will no longer file electioneering communication reports, check appropriate box (5) Type the cover period dates (e g , From 07/01/03 To 09/30/03) Enter the report type using one of the following abbreviations (see Calendar of Election and Reporting Dates) If report is for a special election, add "S" in front of the report code (e g , SG3) Quarterly Reports General Election Reports January Quarterly Q4 46 Day Prior G1 April Quarterly Q1 32 Day Prior G2 July Quarterly Q2 1 8th Day Prior G3 October Quarterly Q3 4 th Day Prior G4 Primary Reports 32 Day Prior F1 90 -Day Termination Reports (Candidates Only) 18 Day Prior F2 Termination Report TR 4 Day Prior F3 Check one of the appropriate boxes Original (first report filed for this reporting period) Amendment (an amendment to a previously filed report) Special Election Report Independent Expenditure Report (see Section 106 071, F S ) (6) Type the amount of all contributions this report Cash & Checks Loans Total Monetary (sum of Cash & Checks and Loans) In -kind (a fair market value must be placed on the contribution at the time it is given) (7) Type the amount of all expenditures this report Monetary Expenditures Transfers to Office Account (elected candidates only) Total Monetary (sum of Monetary Expenditures and Transfers to Office Account) (8) Type the amount of other distributions (goods & services contributed to a candidate or other committee by a PC, CCE or PTY). (9) Type the amount of TOTAL monetary contributions to date (parties keep cumulative totals for 2 year periods at a time (e g , 01/01/02 — 12/31/03) Candidates keep cumulative totals from the time the campaign depository is opened through the termination report) (10) Type the amount of TOTAL monetary expenditures to date (parties keep cumulative totals for 2 year periods at a time (e g , 01/01/02 — 12/31/03) Candidates keep cumulative totals from the time the campaign depository is opened through the termination report). (11) Type or print the required officer's name and have them sign the report Candidate report (treasurer & candidate must sign) PC report (treasurer & chairperson must sign) CCE report (treasurer must sign) PTY report (treasurer & chairperson must sign) Electioneering Communication report (individual or organization's treasurer & chairperson must sign) AMENDMENT REPORTS: An amendment report summary should summarize only contributions, expenditures, distributions, & fund transfers being reported as additions or deletions. Read the instructions for the sequence number & amendment type fields on the back of forms DS -DE 13, 14, 14A and 94. The Division will summarize all reports submitted for each reporting period and for the filer to date. FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY (1) Jr PI o t ) f`" 8 ) a SS OFFICE USE ONLY Name (2) 1 l 5 Tex v Address (num street) .�, Ll O 1 w '? - =r City, Stat , Zip Code ! t.. �+'� c ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: c ' rro (4) Check appropriate box(es): v ❑ Candidate (office sought): _ �c ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED 1 1 CD ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED rri ❑ Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 3 / 3 / 13 To C / G / Report Type T R ❑ Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $1 00 t0 6Z VI Expenditures $ 3 7 Loans $ Vow Transfers to Office Account $ Z6 Total Monetary $ Total Monetary $ 3 7 In -Kind $ (8) Other Distributions $ A/4 u (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ $ (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 (Type name) (Type name) Individual (only for ❑ Treasurer ❑ Deputy Treasurer ❑ Candidate ❑ Chairperson (only for PC, PTY & electioneering commun) ctio eenng commun organization) X X t r Signature Signature DS -DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name D ✓ I5 -( ®1r110 ri (2) I.D. Number ( (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 1 L0 / / / / / / / / / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TRrnTS REPORT - ITEMIZED EXPENDITURES ( , (1) Name 0 V (2) I.D. Number (3) Cover Period / / through / / (4) Page of (5) (7) (8) (9) (10) (11) Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought if Street Address & contribution to a Expenditure Sequence City, State, Zip Code candidate) Type Amendment Amount Number (' /' A3 Fzo I0 irw 37 i L ( / Ld 26 3 Z e pa. v we 'IA / / / / / / / / / / / / DS 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY ( DR PIOTR BLASS OFFICE USE ONLY Name ( 113 W TARA LAKES Address (number and street) BOYNTON BEACH FL 33436 City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: (4) Check appropriate box(es): n Candidate (office sought): ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication Li CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From o3 / 03 / 2013 To 06 / 06 / 2013 Report Type TR ❑ Original 2 Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ Expenditures $ 42.20 Loans $ 200.00 Transfers to Office Account $ Total Monetary $ Total Monetary $ In -Kind $ (8) Other Distributions $ 257.80 (9) TOTAL Monetary Contributions To Date (10) TOT Mo etary Expenditures To Date $ 300.00 v � +t 300. (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 (Type name) (Type name) D individual (only for ❑ Treasurer ❑ Deputy Treasurer ❑ Candidate ❑ Chairperson (only for PC, PTY & eiectioneenng commun) eiectioneenng commun organization) x , I ?) AM x ;) -(AVA4 Signature Signature DS -DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name DR. PIOTR BLASS (2) I.D. Number (3) Cover Period 03 / 03 / 2013 through 06 / 06 / 2013 (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 DR PIOTR BLASS 1 MATHEMAT LOA 200.00 03 / 03 /2013 113 W TARA LAKES ICIAN BOYNTON BEACH FL g 33436 1 / / / / / / / / / / / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name DR PIOTR BLASS (2) I.D. Number (3) Cover Period 03 / 03 / 2013 through 06 06 2013 (4) Page of (5) ( (8) (9) (10) ( Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought if Street Address & contribution to a Expenditure Sequence City, State, Zip Code candidate) Type Amendment Amount Number / FEES TO US + CITY+ SOE FEES DIS $37.00 06 /01/13 1 DR PIOTR BLASS LOAN REPAYMENT REF $257.80 06 /05 /13 113 W TARA LAKES BOYNTON BEACH FL 33436 2 / / / / / / / / / / / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES