State of West Virginia Campaign Financial Statement
(Long Form) in Relation to the 2012 Election Year

Candidate or Committee Name
Candidate or Committee's Treasurer
Political Party (for candidates)
Treasurer's Mailing Address (Street, Route, or P.O. Box)
Office Sought (for Candidates)
House of Delegates
City, State, Zip Code
MAYSEL, WV 25133
Daytime Phone #

Election Cycle Reporting Period (check one):

Primary - First Report
Due Mar 31-Apr 06, 2012Mar 31-Apr 06, 2012
Pre-primary Report
Due Apr 23-Apr 27, 2012Apr 23-Apr 27, 2012
Post-primary Report
Due May 21-Jun 19, 2012May 21-Jun 19, 2012
General - First Report
Due Sep 24-Sep 28, 2012Sep 24-Sep 28, 2012
Pre-general Report
Due Oct 22-Oct 26, 2012Oct 22-Oct 26, 2012
Post-general Report
Due Nov 19-Dec 19, 2012Nov 19-Dec 19, 2012

Check if Applicable:

Amended Report
You must also check box of appropriate reporting period
Final Report
Zero balance required.
PAC must also file Form F-6 Dissolution

Non-Election Cycle Reporting Period:

Annual Report 2012 Calendar Year
Due last Saturday in March or within 6 days thereafter

Report Totals

Fill in totals at the completion of the report.

RECEIPTS OF FUNDS: Totals for this Period
Contributions  $5,225.00
Monetary Contributions from all Fund-Raising Events +$0.00
Receipt of a Transfer of Excess Funds +$0.00
Total Monetary Contributions: =$5,225.00
In-Kind Contributions +$0.00
Total Contributions: =$5,225.00
Other Income  $0.00
Loans Received +$800.00
Total Other Income: =$800.00
Unpaid Bills  $0.00
Outstanding Loans +$0.00
Total Debts: =$0.00
(Add total contributions from all reports)
Beginning Balance
(ending balance from previous report)
Total Monetary Contributions +$5,225.00
Total Other Income +$800.00
Subtotal: a. =$6,025.00
Total Expenditures Paid  $2,696.01
Total Disbursements of Excess Funds +$0.00
Repayment of Loans +$800.00
Subtotal: b. =$3,496.01
Ending Balance:
(Subtotal a. - Subtotal b.)

*Cannot be negative balance
(Add total expenditures from all reports)

$250.00 or LESS

2/15/2012Artie and Vicky Samples$200.00
2/14/2012R.T Sizemore Jr$200.00
2/17/2012David and Janet Meade$200.00
2/20/2012Barry and Roberta Faile$50.00
2/20/2012Paul and Debra Hardesty$200.00
3/16/2012Pat Fromm$100.00
3/16/2012Marc Harmon$100.00
3/16/2012Maria Pedro$100.00
3/16/2012WV Automobile and Truck Dealers $200.00
3/16/2012Domonion PAC$250.00
3/15/2012WV OM&GA$100.00
3/15/2012WV Trucking$100.00
3/28/2012Ruby Shamblin$100.00
3/30/2012Dennis and Suzanne Legg$200.00
3/29/2012Vivian Maynor$50.00
3/22/2012Mountaineer Mini Storage$100.00
3/22/2012Larry and Sue Gillespie$100.00
3/22/2012Edward and Kathy Sizemore$25.00
3/22/2012Shawn Krajeski$150.00
3/22/2012Jeremy and Erica Samples$150.00
3/22/2012Katie Walker$200.00
3/22/2012Michael Mullins$150.00
3/22/2012Dan Greear$100.00
3/27/2012Tom Sizemore$100.00
3/27/2012WV Coal$250.00
 Subtotal of contributions of $250.00 or less$3,725.00

More than $250.00

3/20/2012 Full Name:  Teddy Adkins
Address:  Resident
14485 S Calhoun Highway
Arnoldsburg, WV 25231

Contributor's Job: (individual contributor only)  Oil and Gas Operator
Where Contributor Works: (individual contributor only)  self
Affiliation: (political committee only)  friend
3/22/2012 Full Name:  Dr. and Mrs. Chad Sizemore
Address:  Resident
4123 Cove Point Drive
Morgantown, WV 26508

Contributor's Job: (individual contributor only)  Physician
Where Contributor Works: (individual contributor only)  WV University Hospitals
Affiliation: (political committee only)  son
 Subtotal of all contributions of more than $250.00
Subtotal of all contributions of $250 or less
Total Contributions:

Fund-Raising Events

All monetary contributions received at a fundraiser must be reported in the Event Summary below.
If contributor's name and amount are not listed, the contribution must be turned over to the West Virginia General Revenue Fund. The only exception to this rule may apply to political party executive committees. (WV Code 3-8-5a).

Dan Sizemore kickoff fundraiser Event Summary

Date of Event: 3/22/2012 Total Monetary Contributions:  $0.00
Type of Event: Meet and Greet reception Total Expenditures: -$383.01
Name of Place Held: Clay Senior Center NET RECEIPTS: =($383.01)
Address of Place Held: Go Mart Drive
Clay, WV 25043
Total In-Kind Contributions Related to the Fundraiser  $0.00

$250 or Less

 Subtotal of event contributions of less than $250.00 $0.00

More than $250

 Event contributions of $250 or more: 
Event contributions of less than $250: 
Total Contributions: 

Other Income: Interest, Refunds, Miscellaneous Receipts

DateSource of IncomeType of ReceiptAmount
  Total Other Income: $0.00

In-Kind Contributions

DateName and Contributor InformationDescription of ContributionValue
  Total In-Kind Contributions: $0


West Virginia Code: §3-8-5f. Loans to candidates, organizations or persons for election purposes.

"Every candidate, financial agent, person or association of persons or organization advocating or opposing the nomination or election of any candidate or the passage or defeat of any issue or item to be voted upon may not receive any money or any other thing of value toward election expenses except from the candidate, his or her spouse or a lending institution. All loans shall be evidenced by a written agreement executed by the lender, whether the candidate, his or her spouse, or the lending institution. Such agreement shall state the date and amount of the loan, the terms, including interest and repayment schedule, and a description of the collateral, if any, and the full names and addresses of all parties to the agreement. A copy of the agreement shall be filed with the financial statement next required after the loan is executed."

The loan agreement must include all items asked for in the statute. (See above.) The loan agreement does not have to follow a certain format; generally, if all the required information is listed, any format is acceptable. Candidates or political committees that take out a loan for the campaign through a bank or other commercial lending institution must include a copy of the loan agreement executed with that bank or institution. Candidates should not take out loans which are partially for personal use and partially for the campaign. It is almost impossible to keep reporting straight in this case. Any money a candidate contributes to his or her campaign committee with the hope of repayment must be treated as a loan and reported in this section. When a candidate determines that no further repayment can be expected, the loan can be reported as repaid in this section by entering the amount left to repay in the repayments column and reporting the same amount as a contribution from the candidate on Page 2. These loans must be executed in writing. Caution: Candidates may not carry outstanding loans from one campaign to the next. Each campaign is separate. Funds from a current campaign cannot be used to repay a loan from a previous campaign.

How To Report Loans

  1. Each loan for your campaign should be listed on a separate line. (Each time you loan money to the campaign or get a loan, it is considered to be a separate loan.) Include the following information ont he form below.
    1. loans(s) from prior reporting periods and the balance of each loan (Col A.) If a payment was made on the loan, list that in Col. C. Any loan that was repaid in previous reporting periods does not need to be listed.
    2. new loans, the amount (Col. B), any repayments (Col. C), and the balance (Col. D.)
  2. Attach a copy of the loan agreement for each loan received during the reporting period.

Loans (Continued)

Bank Loans: List name & address or financial institution
Candidate or Candidate's Spouse Loans: List name, residence and mailing address of person(s) making or cosigning loan
Column A
Balance of previous loan at end of period
Column B
Amount of new loan received during period
Column C
Repayments during period
Column D
Balance outstanding at end of period
Amount Date Amount Date Amount Amount
1. Dan Sizemore
4253 Procious Maysel Road
Maysel, WV 25133
1/28/2012 $800.00 3/30/2012
Loans Received Repayment of Loans Outstanding Loans
Totals: $800.00 $800.00 $0.00

Itemized Expenditures

DateName of Person or Vendor And AddressPurposeAmount
1/28/2012 Secretary of State
1900 Kanawha Blvd E
Charleston, WV 25305
Filing Fees$100.00
2/28/2012 Signature Signs
564 Elk River Road
Procious , WV 25164
3/1/2012 WYAP
Main Street
clay, WV 25043
radio ad$20.00
2/10/2012 Frog Pond Printery
PO Box 135
Maysel, WV 25133
signs pens note pads cards$1,300.00
3/16/2012 Clay Senior Center
go mart lane
Clay, WV 25043
building rental$35.00
3/26/2012 Frog Pond Printery
PO Box 135
Maysel, WV 25133
3/21/2012 Kroger
elkview plaza
Elkview , WV 25001
3/21/2012 Smith Foodfair
main Street
Clendenin, WV 25002
3/27/2012 Signature Signs
564 Elk River Road
Procious, WV 25164
3/28/2012 Clay County Little League
clay park
Clay, WV 25043
Sign rental space$100.00
3/28/2012 Signature Signs
564 Elk River Road
Procious, WV 25164
3/29/2012 Signature Signs
564 Elk River Road
Procious, WV 25164
3/22/2012 Clay Family Dollar
555 Main Street
Clay, WV 25043
3/22/2012 Foodland
2200 Main Street
Clay, WV 25043
4/3/2012 Clay Farm Bureau
111 Main Street
Clay, WV 25043
Signs hangers$45.70
  Total Expenditures: $2,696.01

Receipt of a Transfer of Excess Funds

DateCandidate Committee Name and YearAmount
 Total Receipts of Transfer of Excess Funds: $0.00

Disbursement of Excess Funds

DateName of candidate committee and election year disbursing excess fundsPurpose of DisbursementAmount
  Total Disbursement of Excess Funds: $0

Unpaid Bills

DateGroup or Firm AffiliationPurposeAmount
  Total Unpaid Bills: $0.00

Office Use Only
Filed With West Virginia Secretary of State
Tuesday, April 3, 2012 12:20:59 PM