state of georgia campaign contribution disclosure report

State of GeorgiaCampaign Contribution Disclosure Report

1. Report Type(Select One)

[3 Original Report

CU Amended Report

Amendment #

2. Filing is being made on behalf of (Select One):[3 Candidate or Public Official

Office Sought or Held: Columbus City Council Post 10(Include county, municipality, district, pan! or judicial c

Committee Name: Friends of Skip Henderson

[~~l Report of Organization or Person Other than Candidate's Campaign Committee

Filing office use only

Use Earlier of Post

Mark or Hand

Delivered Date

3. Identifying and Contact Information

(1) Berry H. "Skip" Henderson IIIFull Name: of Candidate or Non-Candidate Campaign Committee

(3) 9523 Comanche Rd Columbus . Georgia 31904

(2) Jun 30. 2009Today'* Date

Mailing Addrex*

(4)(706) 325-2576

City

and/or (706) 321-9024

Zip Code

Contact Phone Number (We will understand the release of this information ax permit

(5) If a Candidate or Public Official, is there a campaign committee (one or more persons) to make campaign transactions, keep the financial records of the

campaign, or file the reports? [7] Yes Q] No (6) If so. is the committee registered with the State Ethics Commission'1 [7] Yes |~~1 No

Jimmy MonfortName of Chairperson and/or Tre

4. Period for which you are Reporting

My Non Election Year

0 June 30, 2009 (year)

D Dec. 31, (year)

*Pen,ons leaving office with excess funds untilsuch funds are expended as provided in die Act

until such funds are expended, or such unpaiddebts are satisfied (December 3 1 filing only)

My Elccdon Year

O March 31, (year)

D June 30, (year)

D September 30, (year)

Fl October 25, (year)

n December 3 1 , (year)

Run-Offs(Report requirtd only ifyou are in a Run-Off

Election)

1 1 6 days before PrimaryRun-Off, (year)

|~| 6 days before GeneralRun-Off, (year)

Q 6 days before SpecialPrimary Run-Off,

(year)|~~l 6 days before Specia!

Run-Off, (year)

Special ElectionsiReporl required only ii 'yuu are in a .Special

1 1 1 5 days beforeSpecial Primary,

(year)

[~1 15 days beforeSpecial, (year)

D Dec. 31, (year)

State of Georaia

Verification by Oath or Affirmation

County of Muscoaee

I, Serrv H. "Skip" Henderson III , beinj;that ihe information in this report form is complete, true, and correct. Fu

are tht; same as the contents in the electronic filing submitted, if also ele

Sworn to and subscribed before m; on \ ̂ \ ^^ , 20 VO

cKL&Jgl^ . ^ cSigiaSre of Notary PuWc

^ \Mv Commission expire* && \ V ̂

duly sworn (affirm), depose and

rther, I affirm that the contents in

:tronically filed.

^^iJ iAfiJ^JJ

ayhis report

r*a. Signature of Candidateb. Organization/Chaiiperson/Treasurer

An> person *ho knowingly falls to complv Mth or who k' -,0.< :r..i > Molotos ;,ny 01 rhc :lro\isiooi or ttu- Fthics ill Covcranlcnr \.r - ,..1 Si,, i.:'.. ot '. roiMk-nm.loor


Summary ReportCONTRIBUTIONS RECEIVED

i

2

3

3a

3b

3c

3d

4

5

6

E3 1 have no contributions to report.[ 1 I have the following contributions, including Common Source, to report:

A. If this is the first time to file a disclosure report for the current office soueht.ENTER 0 in both columns (one time only); or

B. If this is the first report of this Reporting Cycle*, ENTER 0 in the in-kind columnand list any net balance on hand brought forward from the previous reporting cyclein the cash amount column (Line 13 of previous report, or total funds left over atyear end of previous cycle); or

C. If this filing is the second or subsequent films of this Reoortine Cvcle. list totalsfrom Line 6 of previous report in both the in-kind and cash amount columns.Total amount of all itemized contributions received in this reporting period which arelisted on the "Itemized Contributions" page.

All loans received this reporting period.

Interest earned on campaign account this reporting period.

Total amount of investments sold this reporting period.

Total amount of cash dividends and interest paid out this reporting period.

Total amount of all separate contributions of less than $ 1 0 1 .00 received in thisreporting period and not listed on the "Itemized Contributions" page."Common Source" contributions must be aggregated on the "Itemized Contributions" page.Total contributions reported this period.(Line 3 + 3a + 3b + 3c + 3d + 4)Total contributions to date. Total to be carried forward to next report of this reporting cycle*.

(Line 2 + 5)

In-KindEstimated Value

•$0.00

$0.00

Cash Amount

$3,266.40

m$0.00

$3,266.40

EXPENDITURES MADE

7

8

9

10

11

12

PI 1 have no expenditures to report.[71 1 have the following expenditures to report:

Total expenditures made and reported prior to this reporting period. If this is theA. First report of this Reporting Cycle*, ENTER 0.B. Second or subsequent filina ENTER Line 12 of previous report.Total amount of all itemized expenditures made in this reporting period which areisted on the "Itemized Expenditures" page.

Total amount of all separate expenditures of less than $ 1 0 1 .00 that were madein this reporting period and not listed on the "Itemized Expenditures" page.Total expenditures reported this period.(Line 9+ 10)Total expenditures to date. Total to be carried forward to next report of this reporting cycle*.

(Line 8+ 11)

In-KindEstimated Value

$0.00

$0.00

INVESTMENTS13

14

15

Total value of investments held at the beginning of this reporting period.

Total value of investments held at the end of this reporting period.

Net balance on hand.(Line 6- 12+ 14) "•"•"

Cash Amount

$891.24

$250.00

$250.00

$1,141.24

$2,125.16

* O.C.G. A. 2 1 -5-34(b)f ! )(D)(ii) A reporting cycle shall commencondude:

(I) Al the expiration of the lerm of office if such candidate is elected and does not seek reelection o

(H) On December 31 of the year in which such election was held if such candidate is unsuccessful;

(Mi) If such candidate is successful and seeks reelection or seeks election to some other office die cu

January 1 of the year in which an election is to be held for the public office to which a candidate seeks election and si

lection to some other office;

:nt reporting cycle shall end when the repotting cycie for reeieclio

Public Officer/Candidate/N on -Candidate Committee Name Berry H. "Skip" Henderson III


Outstanding Indebtedness

1

2

3

4

5

6

7

Outstanding indebtedness at the beginning of this reporting period.

Loans received this reporting period.

Deferred payment of expenses this reporting period

Payments made on loans this reporting period.

Credits received on loans this reporting period.

Payments this reporting period on previously deferred expenses.

Total indebtedness at the close of this reporting period.(Line 1 + 2 + 3 - 4 - 5 - 6 )

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Outstanding indebtedness at the beginning of this reporting period. $0.00

Loans received this reporting period. $0.00

Deferred payment of expenses this reporting period $0.00

Payments made on loans this reporting period. $0.00

Credits received on loans this reporting period. $0.00

Payments this reporting period on previously deferred expenses. $0.00

Total indebtedness at the close of this reporting period.line 1 + 2 + 3 - 4 - 5 - 6 )

Outstanding indebtedness at the beginning of this reporting period.

$0.00

$0.00

Loans received this reporting period. $0.00

Deferred payment of expenses this reporting period $0.00

Payments made on loans this reporting period. $0.00

Credits received on loans this reporting period. $0.00

Payments this reporting period on previously deferred expenses. $0.00

Total indebtedness at the close of this reporting period.(Line 1 + 2 + 3 - 4 - 5 - 6 ) $0.00

* Election Cycle (Primary, General, Special, Special Primary, Run-Off Primary, Run-Off General, Run-Off Special,Run-Off Special Primary)

Public Officer/Candidate/Noii-Candidate Committee Name Berry h. "Skip" Henderson III


Itemized ContributionsMust list contributions received by a single contributor for which the aggregate total is $101.00 or more

Note: Loans are no longer reported in "Itemized Contributions" section. See Loan Reporting section below.

Full Name of ContributorMailing Address(Affiliation of Committee if any)

Contributor

Received DateContribution Type*

Occupation &Employer

ElectionCycle**

CashAmount

$0.00

$0.00

$0.00

$0.00

$0.00

In-Kind Contributions

Estimated ValueDescription

$0.00

$0.00

$0.00

$0.00

$0.00

Itemized Contributions Page Total $ Q.OO $ Q.OO

Loan Reporting

Name of LenderMailing Address

Date of LoanAmount of LoanElection Cycle**

$0.00

$0.00

Person(s) responsible forrepayment of loan

Mailing Address

i.

2.

1.

2.

Occupation &Place of EmploymentFiduciary Relationship***

Reference: OCGA § 21-5-34(b)(l) Loan Page Tola $ Q.OO

SEC FORM CCDRRFV 03/2008


Itemized ExpendituresMust list expenditures made to a single recipient for which the aggregate total is $101.00 or more

Jst Name and Mailing Addressof Recipient

'urple and Gold Golf TournamentOmega Psi Phi Fraternity712 2nd Avenue Cols. Ga. 31901

Expenditure DateExpenditure Type*

6-16-09

Occupation &Employer

:raternal Organization

Expenditure Purpose

:ull page ad in tournamentprogram

Amount Paid

$ 250.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

Page Total 250.00

Expenditure Type (Expenditure, In-Kind, Loan Repayment, Refund, Reimbursement, Credit Card, 3rd Party, Deferred PaymentPayment on Deferred Expense, Investment)

Public Officer/Candid ate A on-Candidate Committee Name Berry H. "Skip" Henderson III

SEC FORM CCDRRev 3/2008


Investments Statment

. Investment NameAccount Number

Institution/Person

Mailing Address

City, State, Zip

Value at beginning of reporting period $

Value at end of reporting period $

Difference in value $

Interest Paid Out $

Cash Dividends $

0.00

0.00

0.00

0.00

0.00Investment Transactions

Date Person/si Involved in Transaction Value of investment purchased Value of investment sold Profit Loss

2. Investment Name

Institution/PersonHolding Account

Mailing Address

City, State, Zip

Account Number

Value at beginning of reporting period $

Value at end of reporting period $

Difference in value $

Interest Paid Out $

Cash Dividends $

0.00

0.00

0.00

0.00

0.00Investment Transactions

Date Personal Involved in Transaction Value of investment purchased

Total value of investments at beginning of reporting period $ 0.00

Tota value of investments at end of renortine period $ 000

Total difference in value $ 0.00

Value of investment sold

Page Total Cash Dividends

Page Total Interest Paid Out

Page Total Profit

Page Total Loss

Profit Loss

$ 0 00

$ 0.00

S 0.00

$ 0.00

Public Officcr/Candidate/Non-Caiididate Committee Name Berry H. "Skip" Henderson III


Addendum StatementThe Addendum Statement should be used for explanation of any additional information needed to complete an accurate filing of this report.

Public Officer/Candidate/Non-Candidate Committee Name BeiTY H. "Skip" HenderSOH III Page_

state of georgia campaign contribution disclosure report

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