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SEC FORM CCDR

REV 06/2009 FILER ID: C2009000102

State of Georgia
Campaign Contribution Disclosure Report
1. Report Type 2. Filing is being made on behalf of: Filing Office Use
Candidate or Public Official Only
E-Filed on
Original Report C2009000102 - 1/6/10 10:32 am
Committee to Elect Jim Nichols
James Attaway Nichols IV Use Earlier of Post
State Representative, District 109 Mark or Hand
Delivered Date
3. Identifying and Contact Information
(1) James Attaway Nichols IV (2) 01/04/2010
Full Name of Candidate or Non-Candidate Campaign Committee Today's Date

(3) 217 Turnstone Rd Stockbridge, GA 30281


Mailing Address

(4) (770) 312-6736


Contact Phone Number (We will understand the release of this information as permission to call your office if necessary.)

(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? YES (6) If so, is the Committee registered with the State Ethics Commission? YES

(7) Chairperson: Jim Nichols Treasurer: David Bucovaz


Name of Chairperson and / or Treasurer of Committee

4. Period for which you are Reporting

My Non Election Year My Election Year Run-Offs Special Elections


(Report Require Only if you are in a Run Off (Report Require Only if you are in a Special
Election) Election)

June 30, 2009 March 31, 2009 6 days before Primary 15 days before
Run-Off, 2009 Special Primary,
X Dec. 31, 2009
June 30, 2009 2009
Persons elected to office in each year 6 days before General
following the year in which the election
occurs
Run-Off, 2009 15 days before
September 30, 2009 Special, 2009
Persons leaving office with excess funds
until such funds are expended as provided in
6 days before Special
the Act Primary Run-Off,
October 25, 2009
Unsuccessful candidates with excess funds, 2009
or who receive contributions to retire debt Dec. 31, 2009
incurred, until such funds are expended, or
December 31, 2009 6 days before Special
such unpaid debts are satisfied (December
31 filing only) Run-Off, 2009

The electronic filing of this document constitutes an affirmation that the statement is true, complete,
and correct. As per modifications of the Ethics in Government Act, filing a separate notarized
affidavit is no longer required. See O.C.G.A. §§ 21-5-34.1(e) and 21-5-50(e).

Campaign Contribution Disclosure Report for 2009 December 31st - Non-Election Year - Original
Electronically Filed with the State Ethics Commission on: 1/6/2010 10:32:20AM -- Confirmation #C200900010224112
SEC FORM CCDR
REV 06/2009 FILER ID: C2009000102
State of Georgia
Campaign Contribution Disclosure Report
Summary Report
CONTRIBUTIONS RECEIVED
1 I Have: In-Kind Cash Amount
The following contributions, including Common Source, to report: Estimated Value

2 Total contributions previously reported.


$45.00 $885.00

3 Total amount of all itemized contributions received in this reporting period which are
listed on the "Itemized Contributions" page. $0.00 $450.00

3a All loans received this reporting period. $0.00


3b Interest earned on campaign account this reporting period.
$0.11
3c Total amount of investments sold this reporting period.
$0.00
3d Total amount of cash dividends and interest paid out this reporting period.
$0.00
Total amount of all separate contributions of less than $101.00 received in this
4 reporting period and not listed on the "Itemized Contributions" page.
"Common Source" contributions must be aggregated on the "Itemized Contributions" page. $104.75 $960.00
Total contributions reported this reporting period.
5
(Line 3 + 3a + 3b +3c + 3d + 4) $104.75 $1,410.11
6 Total contributions to date.
$149.75 $2,295.11
(Line 2 + 5)

EXPENDITURES MADE
I Have: In-Kind Cash Amount
7
The following expenditures to report: Estimated

8 Total expenditures made and reported prior to this reporting period.


$38.00 $446.02
9 Total amount of all itemized expenditures made in this reporting period which are
listed on the "Itemized Expenditures" page. $0.00 $270.00
10 Total amount of all separate expenditures of less than $101.00 each that were made
in this reporting period and not listed on the "Itemized Expenditures" page. $106.75 $264.67
11 Total expenditures reported this reporting period.
(Line 9 + 10) $106.75 $534.67
12 Total expenditures to date.
$144.75 $980.69
(Line 8 + 11)

INVESTMENTS
13 Amount of investments at the beginning of this reporting period. $0.00
14 Total amount of investments at the close of this reporting period. $0.00

15 Net Balance On Hand.


$1,314.42
(Line 6 - 12 + 14)

Campaign Contribution Disclosure Report for 2009 December 31st - Non-Election Year - Original
Electronically Filed with the State Ethics Commission on: 1/6/2010 10:32:20AM -- Confirmation #C200900010224112
SEC FORM CCDR
REV 06/2009

State of Georgia
Campaign Contribution Disclosure Report
Outstanding Indebtedness
Primary 2010 Indebtedness Amount

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

2 Loans received this reporting period. $0.00

3 Deferred payments of expenses this reporting period. $0.00

4 Payments made on loans this reporting period. $0.00

5 Credits received on loans/deferred payments this reporting period. $0.00

6 Payments this period on previously deferred expenses. $0.00

7 Total indebtedness at the close of this reporting period.


$0.00
(line 1 + 2 + 3 - 4 - 5 - 6)

Campaign Contribution Disclosure Report for 2009 December 31st - Non-Election Year - Original
Electronically Filed with the State Ethics Commission on: 1/6/2010 10:32:20AM -- Confirmation #C200900010224112
SEC FORM CCDR
REV 06/2009 FILER ID: C2009000102

State of Georgia
Campaign Contribution Disclosure Report
Itemized Contributions
Must list contributions received by a single contributor for which the aggregate total is $101.00 or more

Contributor In-Kind Contributions


Full Name of Contributor
Mailing Address Received Date a. Occupation & Election Cash Estimated Value
(Affiliation of Committee if any) Contribution Type b. Employer Cycle Amount Description

Eagle, Ryan 12/31/2009 a. Teacher 2010 $300.00 $0.00


b. Los Angeles City Primary
4614 Finley Ave #1 Monetary
Los Angeles, CA 90027 College

Fayette County Democratic 07/25/2009 2010 $150.00 $0.00


Primary
Committee Monetary
P. O. Box 1223
FAYETTEVILLE, GA 30214
(Democratic Party)

FILER ID: C2009000102


State of Georgia
Campaign Contribution Disclosure Report
Summary of Itemized Contributions Received
In-Kind Total for this period: $0.00

Cash Contributions Total for this period: $450.00

Campaign Contribution Disclosure Report for 2009 December 31st - Non-Election Year - Original
Electronically Filed with the State Ethics Commission on: 1/6/2010 10:32:20AM -- Confirmation #C200900010224112
SEC FORM CCDR
REV 06/2009 FILER ID: C2009000102

State of Georgia
Campaign Contribution Disclosure Report
Loan Reporting
Date of Loan Person(s) responsible for Occupation &
Name of Lender Amount of Loan repayment of loan Place of Employment
Mailing Address Election Cycle Mailing Address Fiduciary Relationship

I have no loans to report this reporting period.

Campaign Contribution Disclosure Report for 2009 December 31st - Non-Election Year - Original
Electronically Filed with the State Ethics Commission on: 1/6/2010 10:32:20AM -- Confirmation #C200900010224112
SEC FORM CCDR
REV 06/2009
FILER ID: C2009000102

State of Georgia
Campaign Contribution Disclosure Report
Itemized Expenditures
Must list expenditures made to a single recipient for which the aggregate total is $101.00 or more

List Name and Mailing Address of Expenditure Date Occupation & Expenditure Purpose Amount
Recipient Expenditure Type Employer Paid

Henry County Democratic Committee 12/15/2009 5 Tickets to Attend Henry $120.00


PO Box 1018 Expenditure County Dem Christmas Party
McDonough, GA 30253

Leiter, Brian 07/19/2009 a. University Professor Online Advertising $150.00


5555 S. Everett #D16 Expenditure b. University of
Chicago, IL 60637 Chicago

FILER ID: C2009000102


State of Georgia
Campaign Contribution Disclosure Report
Summary of Itemized Expenditures Made
Paid Expenditures Total for this period: $270.00

Campaign Contribution Disclosure Report for 2009 December 31st - Non-Election Year - Original
Electronically Filed with the State Ethics Commission on: 1/6/2010 10:32:20AM -- Confirmation #C200900010224112
SEC FORM CCDR
REV 06/2009

State of Georgia
Campaign Contribution Disclosure Report
Investments Statement
Investment Name There are No Investments this reporting period
Institution/Person Account Number
Holding Account
Address There are No Investments this reporting period Value at beginning of reporting period
Address Value at end of reporting period
City, State, Zip Cash Dividends
Interest Paid Out

Investment Transactions

Campaign Contribution Disclosure Report for 2009 December 31st - Non-Election Year - Original
Electronically Filed with the State Ethics Commission on: 1/6/2010 10:32:20AM -- Confirmation #C200900010224112

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