Osborne finance

Page 1

CAMPAIGN CONTRIBUTION AND EXPENDITURE REPORT State and District Candidates Only To be filed with: Mark Martin, Secretary of State State Capitol, Room 026 Little Rock, AR 72201 Phone (501) 682-5070 Fax (501) 682-3408

For assistance in completing this form contact: Arkansas Ethics Commissio Post Office Box 1917 Little Rock, AR 72203-1917 Phone (501) 324-9600 Toll Free (800) 422-7773

Check if this report is an amendment

THIS FORM CANNOT BE USED FOR THE FINAL REPORT - ALL INFORMATION MUST BE COMPLETE THIS REPORT MUST BE FILED WITH THE SECRETARY OF STATE

1. Name of Candidate

Kyle Osborne Address

P.O. Box 307 City, State and Zip

Phone Number:

Searcy, AR 72143

501-593-5679

Office Sought

District Number:

State Representative District 046

46

Does the candidate have a campaign committee? ( X )Yes ( If yes, complete the following: Name of Chairperson/Treasurer:

)No

(Secretary of State File Stamp)

Sharon Carder Mailing Address:

Phone Number:

#10 Blackberry Rd.

501-281-7112

2. Type of Election: (check one only) Year of Election:__________ 2012 X General General Runoff Special Primary Primary Runoff 3. Type of Report: (check one only) This report covers what period? ( 10 / 01 / 12 ) through ( 10 / 27 / 12 ) X 10 Day Preelection First Quarter (due April 15) Second Quarter (due July 15) Third Quarter (due October 15) Fourth Quarter (due January 15)

January Monthly February Monthly March Monthly April Monthly

SUMMARY

4. 5. 6. 7. 8. 9. 10.

June Monthly July Monthly August Monthly September Monthly October Monthly

Special Elections Only: May Monthly November Monthly December Monthly

FOR REPORTING PERIOD

CUMULATIVE TOTAL

Balance of campaign funds at beginning of reporting period 26,358.73 0.00 Interest (if any) earned on campaign account 0.00 Total Loans (enter total from line 12) Total Monetary Contributions (enter total from line 18) 20,050.00 15,884.31 Total Expenditures (enter total from line 27) 30,524.42 Balance of campaign funds at close of reporting period ( ) NO ACTIVITY(check if you have not received contributions, loans, or made expenditures during this reporting period)

0.00 5,000.00 62,800.00 36,759.58

I certify to the best of my knowledge and belief that the information disclosed in this report is a complete, true, and accurate financial statement of my (the candidate’s) campaign contributions and expenditures. ________________________________________________________ Signature of Candidate or Candidate’s Representative

Sworn to and subscribed before me, a Notary Public, in and for___________________, County, Arkansas, on this_____ day of __________________, _______. (Legible Notary Seal) Notary Signature______________________________________________________

My Commission Expires:________________________________________ Note: If faxed, notary seal must be legible (i.e., either stamped or raised and inked) and the original must follow within ten (10) days.

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. § 7-6-201 through § 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


11. LOAN INFORMATION Please Type or Print Do not list loans previously reported DATE

NAME AND ADDRESS OF LENDING INSTITUTION

GUARANTOR(S) IF ANY

12. TOTAL LOANS DURING REPORTING PERIOD

AMOUNT

$

0.00

IMPORTANT The limits on campaign contributions do not apply to loans or contributions made by a candidate from his or her own personal funds to the campaign, or to personal loans made by financial institutions to the candidate and applied to his or her campaign. Any loans made by a candidate to his or her campaign and any loans made by a financial institution to a candidate and applied to his or her campaign shall be reported in Section 11. If a candidate desires to use or raise campaign funds to repay himself or herself for personal funds that he or she contributed to the campaign, then he or she would need to report those personal funds as a loan in Section 11. If a candidate does not desire to use or raise campaign funds to repay himself or herself for personal funds that he or she contributed to the campaign, then those personal funds would not be reported in Section 11. Instead, they would be reported as a campaign contribution either in Section 15 or on line 17, depending upon the amount.

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


13. NONMONEY CONTRIBUTIONS (Does not include volunteer services by individuals)

Date of receipt

Full Name and Address of Contributor

Description of nonmoney item

14. TOTAL NONMONEY CONTRIBUTIONS

Value of nonmoney item

Cumulative Total From This Contributor

0.00

IMPORTANT In addition to monetary contributions, candidates are required to report the receipt of any nonmonetary (“in-kind”) contributions. A candidate receives an inkind contribution whenever a person provides him with an item or service without charge or for a charge which is less than the fair market value of the item or service in question. The value of an in-kind contribution is the difference between the fair market value and the amount charged. In-kind contributions are addressed in greater detail in Sections 205 and 206 of the Commission’s Rules on Campaign Finance & Disclosure.

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. § 7-6-201 through § 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


15. ITEMIZED MONETARY CONTRIBUTIONS OVER $50 Please Type or Print Date

10/01/2012

(Use Additional Copies Of This Page If Necessary) Full Name And Mailing Address Of Contributor Place Of Business/ Employer/Occupation

Amount Of Contribution

Roger or barbara duncan 86 Country club circle searcy, ar 72143

retired same

Primary Election Primary Run-Off X General Election General Run-Off Debt

Roger or barbara duncan 86 Country club circle searcy, ar 72143

retired same

Primary Election Primary Run-Off X General Election General Run-Off Debt

Roger or barbara duncan 86 Country club circle searcy, ar 72143

retired same

Primary Election Primary Run-Off X General Election General Run-Off Debt

J. O. Aunspaugh 111 Bristlecone Rd Searcy, Ar 72143

same

Primary Election Primary Run-Off X General Election General Run-Off Debt

Leon or Margaret Blue 16 Country Club Circle Searcy, Ar 72143

Doctor-WCMC

Primary Election Primary Run-Off X General Election General Run-Off Debt

Jeffrey Rains 100 E. Pleasure Searcy, AR 72143

same Doctor

Primary Election Primary Run-Off X General Election General Run-Off Debt

Rob Young 511 S. Main St Searcy, Ar 72143

Same

Primary Election Primary Run-Off X General Election General Run-Off Debt

Conley Bulk Services P O Box 809 Searcy, Ar 72145

HWY 367

Primary Election Primary Run-Off X General Election General Run-Off Debt

JOHN BELL 505 S. ELM SEARCY, AR 72143

ATTORNEY

Primary Election Primary Run-Off X General Election General Run-Off Debt

Cumulative Total From This Contributor

500.00 10/04/2012

500.00 10/04/2012

1,100.00

100.00 10/01/2012

100.00

100.00 10/02/2012

300.00

300.00 10/02/2012

500.00

500.00 10/03/2012

250.00

250.00 10/03/2012

1,000.00

1,000.00 10/03/2012

500.00

500.00 Subtotal of Contributions This Page

3,750.00

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


15. ITEMIZED MONETARY CONTRIBUTIONS OVER $50 Please Type or Print Date

10/03/2012

(Use Additional Copies Of This Page If Necessary) Full Name And Mailing Address Of Contributor Place Of Business/ Employer/Occupation

Amount Of Contribution

BUD GILLHAM 2910 E. MOORE ST. SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

LOWERY DRUG MART 123 CENTRAL AV SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

MARTIN HAWKINS 102 SADDLE RIDGE COVE SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

EMOGENE FOX 5 COUNTRY CLUB CIRCLE SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

JACK WISEMAN PO BOX 808 SEARCY, AR 72145

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

RED MORGAN 405 W. ARCH SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

BETTY MOTE 111 WATER OAK SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

DAVID HATFIELD 32 JAMESTOWN SEARCY, AR 72143

DR. WCMC

Primary Election Primary Run-Off X General Election General Run-Off Debt

JAYTON LIM PO BOX 1424 SEARCY, AR 72145

DR. RACE ST.

Primary Election Primary Run-Off X General Election General Run-Off Debt

Cumulative Total From This Contributor

100.00

100.00 10/03/2012

500.00

500.00 10/03/2012

100.00

100.00 10/03/2012

200.00

200.00 10/03/2012

100.00

100.00 10/03/2012

200.00

200.00 10/03/2012

300.00

300.00 10/03/2012

500.00

500.00 10/03/2012

200.00

200.00 Subtotal of Contributions This Page

2,200.00

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


15. ITEMIZED MONETARY CONTRIBUTIONS OVER $50 Please Type or Print Date

10/04/2012

(Use Additional Copies Of This Page If Necessary) Full Name And Mailing Address Of Contributor Place Of Business/ Employer/Occupation

Amount Of Contribution

dalrymple commerical 1560 w. beebe-capps exp searcy, ar 72143

real-estate

Primary Election Primary Run-Off X General Election General Run-Off Debt

JIMMY SIMPSON 200 S. SPRING SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

Jim Tarkington PO BOX 237 SEARCY, AR 72145

RACE ST. AUTO SALES

Primary Election Primary Run-Off X General Election General Run-Off Debt

DAVID SEWARD 6 COUNTRY CLUB CIRCLE SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

TOMMIE PEMBERTON 412 COUNTRY SQUIRE LN SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

Bobby Reynolds 908 KELBURN Searcy, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

Marla Duncan 2936 w country club rd searcy, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

HUBERT HIGGS 23 COUNTRY CLUB CIRCLE SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

PAUL TEED 204 S CHARLES SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

Cumulative Total From This Contributor

200.00

200.00 10/04/2012

200.00

200.00 10/04/2012

500.00

500.00 10/04/2012

100.00

100.00 10/04/2012

100.00

100.00 10/04/2012

500.00

500.00 10/04/2012

50.00

50.00 10/04/2012

200.00

200.00 10/04/2012

100.00

100.00 Subtotal of Contributions This Page

1,950.00

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


15. ITEMIZED MONETARY CONTRIBUTIONS OVER $50 Please Type or Print Date

10/04/2012

(Use Additional Copies Of This Page If Necessary) Full Name And Mailing Address Of Contributor Place Of Business/ Employer/Occupation

Amount Of Contribution

GRAYLING WHEELER 2390 HWY 16 SEARCY, AR 72143

FLOWER SHOP OWNER

Primary Election Primary Run-Off X General Election General Run-Off Debt

TED STEWARD 109 ORCHID RD SEARCY, AR 72143

LINCOLN ST. AG CHEMICAL

Primary Election Primary Run-Off X General Election General Run-Off Debt

JOEL SKALINDER 2065 E. TETON BLVD GREEN RIVER, WY 82935

BAKER OIL FIELD SUPPLIES

Primary Election Primary Run-Off X General Election General Run-Off Debt

SCOTT BRADY 109 MARK LANE SEARCY, AR 72143

SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

RICKY VANHOOK 1560 W. BEBEE CAPPS EXP SEARCY, AR 72143

LAKE ICE-LINCOLN ST

Primary Election Primary Run-Off X General Election General Run-Off Debt

George Carder PO Box 75 Searcy, AR 72145

Attorney

Primary Election Primary Run-Off X General Election General Run-Off Debt

ADEN WOODRUFF 2200 E. RACE ST. SEARCY, AR 72143

OFFICE SUPPLYRACE ST.

Primary Election Primary Run-Off X General Election General Run-Off Debt

Kerry Campbell 53 Country Club Circle Searcy, AR 72143

Small Business Owner

Primary Election Primary Run-Off X General Election General Run-Off Debt

mike wright 125 emeral lake dr searcy, ar 72143

oakley seed co

Primary Election Primary Run-Off X General Election General Run-Off Debt

Cumulative Total From This Contributor

250.00

250.00 10/04/2012

100.00

100.00 10/04/2012

100.00

100.00 10/04/2012

100.00

100.00 10/04/2012

100.00

100.00 10/04/2012

200.00

200.00 10/04/2012

100.00

100.00 10/04/2012

100.00

100.00 10/04/2012

100.00

100.00 Subtotal of Contributions This Page

1,150.00

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


15. ITEMIZED MONETARY CONTRIBUTIONS OVER $50 Please Type or Print Date

10/08/2012

(Use Additional Copies Of This Page If Necessary) Full Name And Mailing Address Of Contributor Place Of Business/ Employer/Occupation

Amount Of Contribution

Stan-Kel Pharmacies, Inc. 2007 West Beebe-Capps Expy. Searcy, AR 72143

Small business

Primary Election Primary Run-Off X General Election General Run-Off Debt

MIKE ARNETT PO BOX 1346 SEARCY, AR 72145

AR INDUSTRIAL

Primary Election Primary Run-Off X General Election General Run-Off Debt

REYNIE RUTLEDGE PO BOX 1009 SEARCY, AR 72145

FIRST SECURITY BANK

Primary Election Primary Run-Off X General Election General Run-Off Debt

BRUCE HAWKINS DBH MANAGEMENT 19 COUNTRY LANE MARRILTON, AR 72110

DBH MANAGEMENT

Primary Election Primary Run-Off X General Election General Run-Off Debt

sharon carder 10 blackberry rd searcy, ar 72143

carder law firm

Primary Election Primary Run-Off X General Election General Run-Off Debt

WALLS McCRARY CAMPAIGN FUND P O BOX 776 LONOKE, AR 72086

LEGISLATOR

Primary Election Primary Run-Off X General Election General Run-Off Debt

Darrin Williams for State Rep 2010 11311 Arcade Drive Suite 200 Little Rock, AR 72212

Campaign Account

Primary Election Primary Run-Off X General Election General Run-Off Debt

Opportunity PAC P. O. Box 3844 Little Rock, AR 72203

PAC

Primary Election Primary Run-Off X General Election General Run-Off Debt

AP-PAC AR Pharmacists 417 S. Victory Little Rock, AR 72201

Independent Pharmacies

Primary Election Primary Run-Off X General Election General Run-Off Debt

Cumulative Total From This Contributor

1,000.00

1,000.00 10/08/2012

100.00

100.00 10/08/2012

1,000.00

1,000.00 10/08/2012

250.00

250.00 10/08/2012

500.00

500.00 10/10/2012

150.00

150.00 10/10/2012

300.00

300.00 10/10/2012

250.00

250.00 10/10/2012

150.00

150.00 Subtotal of Contributions This Page

3,700.00

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


15. ITEMIZED MONETARY CONTRIBUTIONS OVER $50 Please Type or Print Date

10/11/2012

(Use Additional Copies Of This Page If Necessary) Full Name And Mailing Address Of Contributor Place Of Business/ Employer/Occupation

Amount Of Contribution

CATHY DUNCAN 300 E. MULBERRY SEARCY, AR 72143

THOMPSONS RECYCLING-SAME

Primary Election Primary Run-Off X General Election General Run-Off Debt

Ben Pickard P.O. Box 1331 Searcy, AR 72143

RETIRED

Primary Election Primary Run-Off X General Election General Run-Off Debt

Brenda May 1 Point Lane Forrest City, AR 72335

Nurse

Primary Election Primary Run-Off X General Election General Run-Off Debt

Reginald Murdock Campaign Account P.O. Box 1071 Marianna, AR 72360-1071

State Representative

Primary Election Primary Run-Off X General Election General Run-Off Debt

CATLET TOWER PARTNERSHIP 323 CENTER ST. SUITE. 1800 LITTLE ROCK, AE 72201

BLG. MANAGEMENT

Primary Election Primary Run-Off X General Election General Run-Off Debt

SHAWN OR AMANDA MCCLISH 117 HEFNER SEARCY, AR 72143

AUTO SALESJACKSONVILLE

Primary Election Primary Run-Off X General Election General Run-Off Debt

HAYS INC 1140 HWY 367N JUDSONIA, ar 72081

CLOTHING

Primary Election Primary Run-Off X General Election General Run-Off Debt

JR OR DIANE THOMAS 115 BRISTLECONE SEARCY, AR 72143

AR TOBACCO BOARD

Primary Election Primary Run-Off X General Election General Run-Off Debt

DAVID LAFFOON 60 COUNTRY CLUB CIR SEARCY, AR 72143

RETIRED

Primary Election Primary Run-Off X General Election General Run-Off Debt

Cumulative Total From This Contributor

500.00

500.00 10/11/2012

200.00

200.00 10/11/2012

100.00

100.00 10/11/2012

150.00

150.00 10/11/2012

250.00

250.00 10/12/2012

200.00

200.00 10/13/2012

200.00

200.00 10/14/2012

200.00

200.00 10/19/2012

300.00

300.00 Subtotal of Contributions This Page

2,100.00

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


ITEMIZED MONETARY CONTRIBUTIONS OVER $50 Date

10/20/2012

Please Type or Print Full Name And Mailing Address Of Contributor Place Of Business/ Employer/Occupation

Amount Of Contribution

Linda McIntosh 644 Cain Road Griffithville, AR 72060

Nurse

Primary Election Primary Run-Off X General Election General Run-Off Debt

Greg Leding 50 S. School Ave. Apt. 1 Fayetteville, AR 72701

Arkansas Legislator

Primary Election Primary Run-Off X General Election General Run-Off Debt

Cumulative Total From This Contributor

100.00

100.00 10/20/2012

100.00

100.00 10/25/2012

NELSON J. ROACH 205 LINDA DR DANGERFIELD, TX 75638

RETIRED

Primary Election Primary Run-Off X General Election General Run-Off Debt

Lois Patterson 15 Oakridge Cir. Texarkana, TX 75503

Homemaker

Primary Election Primary Run-Off X General Election General Run-Off Debt

1,000.00

1,000.00 10/25/2012

2,000.00

2,000.00 10/25/2012

CARY PATTERSON P.O. BOX 679 DANGERFIELD, TX 75638

ATTORNEY

Primary Election Primary Run-Off X General Election General Run-Off Debt

2,000.00

2,000.00 Primary Election Primary Run-Off General Election General Run-Off Debt Primary Election Primary Run-Off General Election General Run-Off Debt

Primary Election Primary Run-Off General Election General Run-Off Debt Primary Election Primary Run-Off General Election General Run-Off Debt

16. TOTAL ITEMIZED MONETARY CONTRIBUTIONS OVER $50 17. TOTAL NONITEMIZED MONETARY CONTRIBUTIONS 18. TOTAL MONETARY CONTRIBUTIONS THIS REPORT (includes totals from lines 16 and 17)

20,050.00 0.00 20,050.00

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


19. CAMPAIGN EXPENDITURES BY CATEGORY Please Type or Print CATEGORY

TOTAL AMOUNT

Filing Fee Television Advertising Radio Advertising Newspaper Advertising Other Advertising Office Supplies Rent Utilities Telephone Postage Direct Mail Travel Expenses Entertainment Fundraising Repayment of Loans Returned Contributions Consultant Fees Polls Paid Campaign Workers Other (list)

397.85

15,486.46

20. TOTAL CAMPAIGN EXPENDITURES

15,884.31

21. PAID CAMPAIGN WORKERS (Include any person you paid to work on your campaign, does not have to be full-time worker) NAME OF WORKER AMOUNT NAME OF WORKER PAID

22. TOTAL AMOUNT PAID CAMPAIGN WORKERS

AMOUNT PAID

0.00

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


23. ITEMIZED CAMPAIGN EXPENDITURES OVER $100 Name and Address of Supplier/Payee

Please Type or Print (Use additional copies of this page if necessary) Description of Expenditure Date of Expenditure

Amount of Expenditure

The Markham Group 1000 West 3rd St Little Rock, AR 72201

POSTAGE FOR MAILOUT

10/04/2012

578.75

The Markham Group 1000 West 3rd St Little Rock, AR 72201

CONSULTANT FEES

10/04/2012

9,379.61

The Markham Group 1000 West 3rd St Little Rock, AR 72201

CONSULTANT FEES

10/26/2012

5,528.10

Searcy Signs 509 N Oak Searcy, Ar 72143

SIGNS

10/22/2012

397.85

24. 25. 26. 27.

TOTAL ITEMIZED EXPENDITURES THIS REPORT TOTAL NONITEMIZED EXPENDITURES THIS REPORT TOTAL PAID CAMPAIGN WORKERS THIS REPORT (enter total from line 22) TOTAL EXPENDITURES THIS REPORT (includes lines 24, 25 and 26)

15,884.31 0.00 0.00 15,884.31

Note: All Expenditures Reflected on Lines 24, 25, and 26 Should Be Totaled by Category In Section 19

The law provides for a maximum penalty of $2,000 per violation and/or imprisonment for not more than one year for any person who knowingly or willfully fails to comply with the provisions of A.C.A. ยง 7-6-201 through ยง 7-6-227. This report constitutes a public record. This form has been approved by the Arkansas Ethics Commission. REVISED 08/09


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