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~ch ed u l e B -- Pa rt I Ty.~ or print in ink. <br />Amounts may be rounded Statement covers period <br />Loans Receivedto whole dollars. : ~_ <br />SEE iNSTRUCTIONS ON REVERSE through ' Page <br />NAME OF OFFICEHOLDER OR C~, NDIDATE AND CONTROLLED COMMITTEE I I.D. NUMBER <br /> <br /> LENDER OR GUARANTOR'S FULL NAME AND ADDRESS LENDER / GUARANTOR'S LENDER INFORMATION GUARANTOR INFORMATION <br />DATE <br />t RECE IVY. D 0r COMM~T[EE, £NTER FULL NAME. ADDRESS AND I,D, NUMBER. If NO I,D, OCCUPATION AND EMPLOYER (IF ~LF- <br /> NUMBER HA5 SEEN ASSIGNED. ENTER THE TRCASURER'S NAME AND ADDRESS) EMPLOYED. ENTER RUSlNESS NAME ) DUE DATE~ AMOUNt CUMULATIVE AMOUNT CUMULATr~E <br /> INTEREST RATE OF lOAN TO DATE GUARANTEED TO DAT~ <br /> , <~'~'~ //~/:/~IC~1 ,~j~/~'/~'¢~7 DUE DATE ~.1[.~.~ ~ CALENDAR YEAR CALENDAR YEAR <br /> INTtREst ~ate OTHER OTHER <br /> <br /> [] Lender , ~, Guarantor* / '~ S $ <br /> i [] Lender / [] Guarantor* ' ,,~ S <br /> DUE DATE CALENDAR YEaR CaLeNDAR YEAR <br /> <br /> INTEREST &ATE <br /> OTHER OTHI~R, <br /> [] Lender [] Guarantor* ~ ~ <br /> <br />*$~e h~,,~or~ant ~nstructions on rever~e. SUBTOTAL $ $ <br />Loans Receivad - Part I Summary <br />1. Loans of $100 or more received this period. (Indude all Loans Received - Part l (a) subtotals.) .......... $ ~ ,~ c~ ;) <br />~. Locn~ ~nd~r $100 received this period. (Do not itemize.) ......... $ <br />3. To~l lo~ns received this period. (Add Lines 1 and 2.) ....................................... TOTAL $ /, :' /'~ <br />Loan~ Received - Part II Summary <br />4. Loans of $100 or more repaid, forgiven, or paid by a third party this period. (Include all Part II <br />subtotals. If forgiven or paid by a third party, a/so itemize the transaction on Schedule A.) .............. <br />5. Loans under $100 repaid, forgiven, or paid by a third party. (Do no itemize.) If forgiven or <br />paid by a third party, include this amount on Schedule A Summary, Line 2 ............................ $ <br />6. Total loans repaid, forgiven, or paid by a third party this period. TOTAL $ ( ) <br />(Add Lines4 + $.) ....................................................................... <br />7. Net change this period. (Subtract Line 6 from Line3.) NET $ /: " <br />Enter tho net here and on the Summary Page, Column A, Line 2 ................................ /m,, b~ ..... ,, ..... <br /> <br /> <br />