1.Name

2.Title

3.County

AdairAllenAndersonBallardBarrenBathBellBooneBourbonBoydBoyleBrackenBreathittBreckinridgeBullittButlerCaldwellCallowayCampbellCarlisleCarrollCarterCaseyChristianClarkClayClintonCrittendenCumberlandDaviessEdmonsonElliottEstillFayetteFlemingFloydFranklinFultonGallatinGarrardGrantGravesGraysonGreenGreenupHancockHardinHarlanHarrisonHartHendersonHenryHickmanHopkinsJacksonJeffersonJessamineJohnsonKentonKnottKnoxLaRueLaurelLawrenceLeeLeslieLetcherLewisLincolnLivingstonLoganLyonMadisonMagoffinMarionMarshallMartinMasonMcCrackenMcCrearyMcLeanMeadeMenifeeMercerMetcalfeMonroeMontgomeryMorganMuhlenbergNelsonNicholasOhioOldhamOwenOwsleyPendletonPerryPikePowellPulaskiRobertsonRockcastleRowanRussellScottShelbySimpsonSpencerTaylorToddTriggTrimbleUnionWarrenWashingtonWayneWebsterWhitleyWolfeWoodford

4.Email address

All of the following questions refer to the Distributor and J&J settlement only:

5.How much has your county received to date? ($)

6.Has your county obligated and/or spent any funds yet?

Yes

No