Professional Documents
Culture Documents
AND DISBURSEMENTS
FEC
FORM 3X
1.
TYPE OR PRINT
NAME OF
COMMITTEE (in full)
12FE4M5
CITY
5.
Covering Period
ZIP CODE
3. IS THIS
REPORT
NEW
(N)
OR
AMENDED
(A)
(b) Monthly
Report
Due On:
Feb 20 (M2)
May 20 (M5)
Aug 20 (M8)
Nov 20 (M11)
Mar 20 (M3)
Jun 20 (M6)
Sep 20 (M9)
Dec 20 (M12)
Apr 20 (M4)
Jul 20 (M7)
Oct 20 (M10)
Jan 31 (YE)
C
4. TYPE OF REPORT
(Choose One)
STATE
2.
Check if different
than previously
reported. (ACC)
(c)
12-Day
PRE-Election
Report for the:
Election on
(d)
30-Day
POST-Election
Report for the:
Election on
M M / D D / Y Y Y Y
Primary (12P)
General (12G)
Convention (12C)
Special (12S)
(Non-Election
Year Only)
Runoff (12R)
in the
State of
M M / D D / Y Y Y Y
General (30G)
(Non-Election
Year Only)
Runoff (30R)
M M / D D / Y Y Y Y
Special (30S)
in the
State of
M M / D D / Y Y Y Y
through
I certify that I have examined this Report and to the best of my knowledge and belief it is true, correct and complete.
Type or Print Name of Treasurer
Signature of Treasurer
Date
M M / D D / Y Y Y Y
NOTE: Submission of false, erroneous, or incomplete information may subject the person signing this Report to the penalties of 52 U.S.C. 30109.
Office
Use
Only
FEC FORM 3X
Rev. 05/2016
SUMMARY PAGE
Page 2
M M / D D / Y Y Y Y
From:
COLUMN A
This Period
6. (a) Cash on Hand
January 1,
Y Y Y Y
(b) Cash on Hand at
Beginning of Reporting Period.............
(d) Subtotal (add Lines 6(b) and
6(c) for Column A and Lines
6(a) and 6(c) for Column B)................
7.
8.
9.
M M / D D / Y Y Y Y
To:
COLUMN B
Calendar Year-to-Date
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
This committee has qualified as a multicandidate committee. (see FEC FORM 1M)
of Receipts
Page 3
M M / D D / Y Y Y Y
M M / D D / Y Y Y Y
From:
To:
COLUMN A
Total This Period
I. Receipts
(b) Political Party Committees...................
(c) Other Political Committees
(such as PACs).....................................
(d) Total Contributions (add Lines
11(a)(iii), (b), and (c)) (Carry
Totals to Line 33, page 5)...............
12. Transfers From Affiliated/Other
Party Committees.........................................
13. All Loans Received......................................
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
COLUMN B
Calendar Year-to-Date
, , .
, , .
of Disbursements
COLUMN A
Total This Period
II. Disbursements
(ii) Non-Federal Share.......................
(b) Other Federal Operating
Expenditures........................................
(c) Total Operating Expenditures
(add 21(a)(i), (a)(ii), and (b))..............
22. Transfers to Affiliated/Other Party
Committees..................................................
23. Contributions to
Federal Candidates/Committees
and Other Political Committees..................
24. Independent Expenditures
(use Schedule E)........................................
25. Coordinated Party Expenditures
(52 U.S.C. 30116(d))
(use Schedule F)........................................
Page 4
COLUMN B
Calendar Year-to-Date
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
(b) Political Party Committees..................
(c) Other Political Committees
(such as PACs)....................................
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
(d) Total Contribution Refunds
(add Lines 28(a), (b), and (c))............
, , .
(b)
(c)
of Disbursements
33.
34.
35.
36.
37.
38.
COLUMN A
Total This Period
Page 5
COLUMN B
Calendar Year-to-Date
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
PAGE
OF
11a
11b
11c
12
13
14
15
16
17
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions
or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (In Full)
A.
Full Name of Individual (Last, First, Middle Initial) or Full Organization Name
Mailing Address
City
Date of Receipt
M M / D D / Y Y Y Y
State
Zip Code
Amount of Each Receipt this Period
B.
, , .
Memo Item
, , .
Full Name of Individual (Last, First, Middle Initial) or Full Organization Name
Mailing Address
City
Date of Receipt
M M / D D / Y Y Y Y
State
Zip Code
Amount of Each Receipt this Period
C.
, , .
Memo Item
, , .
Full Name of Individual (Last, First, Middle Initial) or Full Organization Name
Mailing Address
City
Date of Receipt
M M / D D / Y Y Y Y
State
Zip Code
Amount of Each Receipt this Period
Memo Item
, , .
General
, , .
Receipt For:
Primary
Other (specify)
, , .
, , .
FEC Schedule A (Form 3X) Rev. 06/2016
PAGE
OF
21b
22
23
26
27
28a
28b
28c
29
30b
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions
or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (In Full)
A.
Date of Disbursement
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
Purpose of Disbursement
Candidate Name
Office Sought:
State:
B.
House
Senate
President
District:
Disbursement For:
Primary
General
Other (specify)
Category/
Type
, , .
Memo Item
Date of Disbursement
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
Purpose of Disbursement
Candidate Name
Office Sought:
State:
C.
House
Senate
President
District:
Disbursement For:
Primary
Other (specify)
Category/
Type
, , .
General
Memo Item
Date of Disbursement
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
Purpose of Disbursement
Office Sought:
State:
House
Senate
President
District:
Disbursement For:
Primary
General
Other (specify)
Category/
Type
, , .
Memo Item
Candidate Name
, , .
, , .
FEC Schedule B (Form 3X) Rev. 05/2016
PAGE
OF
Mailing Address
City
State
TERMS
ZIP Code
, , .
, , .
Date Incurred
Date Due
M M / D D / Y Y Y Y
Election:
Primary
General
Other (specify)
Memo Item
, , .
Interest Rate
M M / D D / Y Y Y Y
Secured:
% (apr)
Yes
No
Name of Employer
Mailing Address
Occupation
City
State
ZIP Code
Amount
Guaranteed
Outstanding:
, , .
Name of Employer
Mailing Address
Occupation
City
State
ZIP Code
Amount
Guaranteed
Outstanding:
, , .
Name of Employer
Mailing Address
Occupation
City
State
ZIP Code
Amount
Guaranteed
Outstanding:
, , .
Name of Employer
Mailing Address
Occupation
City
Amount
Guaranteed
Outstanding:
, , .
ZIP Code
, , .
State
, , .
Carry outstanding balance only to LINE 3, Schedule D, for this line. If no Schedule D, carry forward to appropriate line of Summary.
FEC Schedule C (Form 3X) Rev. 05/2016
Supplementary for
Information found on
Page
of Schedule C
C
LENDING INSTITUTION (LENDER)
Full Name
Amount of Loan
M M / D D / Y Y Y Y
, , .
Mailing Address
City
No
M M / D D / Y Y Y Y
Date Due
Yes
, , .
Total
Outstanding
Balance:
M M / D D / Y Y Y Y
, , .
, , .
Does the lender have a perfected security
interest in it?
No
Yes
, , .
Location of account:
Address:
F. If neither of the types of collateral described above was pledged for this loan, or if the amount pledged does not equal or exceed
the loan amount, state the basis upon which this loan was made and the basis on which it assures repayment.
G. COMMITTEE TREASURER
Typed Name
Signature
DATE
M M / D D / Y Y Y Y
AUTHORIZED REPRESENTATIVE
Typed Name
Signature
DATE
Title
M M / D D / Y Y Y Y
(Use separate
schedule(s)
for each
numbered line)
Excluding Loans
PAGE
OF
9
10
Mailing Address
City
State
Zip Code
, , .
, , .
, , .
, , .
Mailing Address
City
State
Zip Code
, , .
, , .
, , .
, , .
Mailing Address
City
State
Zip Code
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
PAGE
OF
FOR LINE 24 OF FORM 3X
C
Check if
24-hour report
48-hour report
New report
Memo Item
M M / D D / Y Y Y Y
Mailing Address
State
Purpose of Expenditure
Category/
Type
Calendar Year-To-Date
Per Election for Office Sought
, , .
Zip Code
M M / D D / Y Y Y Y
Support
Office Sought:
House
District:
Oppose
Senate
State:
President
Disbursement
For:
, , .
Primary
Other (specify)
Memo Item
General
City
Amount
Mailing Address
M M / D D / Y Y Y Y
Support
Office Sought:
House
District:
Oppose
Senate
State:
, , .
President
Disbursement
For:
Primary
Calendar Year-To-Date
Per Election for Office Sought
, , .
Zip Code
Other (specify)
General
Purpose of Expenditure
State
, , .
City
Amount
, , .
, , .
Under penalty of perjury I certify that the independent expenditures reported herein were not made in cooperation, consultation, or concert
with, or at the request or suggestion of, any candidate or authorized committee or agent of either, or (if the reporting entity is not a political
party committee) any political party committee or its agent.
Signature
Date
M M / D D / Y Y Y Y
PAGE
OF
Mailing Address
City
State
Memo Item
Mailing Address
State
Office Sought:
Zip Code
House
Senate
Presidential
M M / D D / Y Y Y Y
State:
District:
Amount
, , .
Memo Item
Purpose of Expenditure
Category/
Type
Mailing Address
City
State
Office Sought:
Date
Zip Code
House
Senate
Presidential
M M / D D / Y Y Y Y
State:
District:
Amount
, , .
, , .
Memo Item
Purpose of Expenditure
Category/
Type
Mailing Address
State
Office Sought:
Date
Zip Code
House
Senate
Presidential
M M / D D / Y Y Y Y
State:
District:
Amount
, , .
, , .
City
Category/
Type
, , .
Purpose of Expenditure
Date
City
ZIP Code
, , .
, , .
FEC Schedule F (Form 3X) Rev. 05/2016
ALLOCATED
ALLOCATED
Federal........................................................................
Nonfederal..................................................................
PAGE
OF
I. FUNDRAISING activities are allocated using the funds received method where the federal proportion of
expenses must equal the federal proportion of monies raised.
II. Shared DIRECT CANDIDATE SUPPORT activities are allocated according to benefit expected to be derived,
where the .federal proportion of disbursements is based on the benefit derived by federal candidates from the activity. For PACs .Only: Direct candidate support includes public communications or voter drives that refer to both
federal and nonfederal candidates, regardless of whether there is a reference to a political party. Such expenses
are allocated using a time/space method.
ACTIVITY OR EVENT IDENTIFIER
ACTIVITY IS:
Fundraising
Direct Candidate Support
CHECK IF THE RATIO IS:
New
Revised
Same as Previously Reported
FEDERAL %
NONFEDERAL %
FEDERAL %
NONFEDERAL %
FEDERAL %
NONFEDERAL %
FEDERAL %
NONFEDERAL %
FEDERAL %
NONFEDERAL %
FEDERAL %
NONFEDERAL %
PAGE
OF
NAME OF ACCOUNT
DATE OF RECEIPT
M M / D D / Y Y Y Y
, , .
, , .
, , .
, , .
, , .
b)
, , .
, , .
, , .
b)
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
, , .
FEC Schedule H3 (Form 3X) Rev. 05/2016
PAGE
OF
State
Zip Code
Administrative
Fundraising
Voter Drive
Purpose of Disbursement:
, , .
FEDERAL SHARE
Category/
Type
M M / D D / Y Y Y Y
Date
NONFEDERAL SHARE
, , .
State
Zip Code
Administrative
Fundraising
Voter Drive
, , .
Category/
Type
M M / D D / Y Y Y Y
Date
NONFEDERAL SHARE
, , .
, , .
TOTAL AMOUNT
, , .
State
Zip Code
Administrative
Fundraising
Exempt
Voter Drive
Purpose of Disbursement:
, , .
Category/
Type
NONFEDERAL SHARE
M M / D D / Y Y Y Y
Date
, , .
, , .
Exempt
Purpose of Disbursement:
FEDERAL SHARE
TOTAL AMOUNT
, , .
, , .
FEDERAL SHARE
Exempt
NONFEDERAL SHARE
, , .
, , .
FEDERAL SHARE
NONFEDERAL SHARE
, , .
, , .
TOTAL AMOUNT
, , .
TOTAL AMOUNT
, , .
TOTAL This Period (last page for each line only)(Federal. share to 21(a)(i) and NonFederal share to 21(a)(ii))
TOTAL AMOUNT
, , .
FEC Schedule H4 (Form 3X) Rev. 05/2016
PAGE
OF
FOR LINE 18b OF FORM 3X
NAME OF ACCOUNT
DATE OF RECEIPT
M M / D D / Y Y Y Y
VOTER REGISTRATION
i) Voter Registration
, , .
, , .
VOTER ID
ii) Voter ID
Total Amount Transferred for Voter ID................................
, , .
GOTV
iii) GOTV
Total Amount Transferred for GOTV..................................................
, , .
, , .
DATE OF RECEIPT
M M / D D / Y Y Y Y
, , .
VOTER REGISTRATION
, , .
VOTER ID
ii) Voter ID
Total Amount Transferred for Voter ID................................
, , .
iii) GOTV
Total Amount Transferred for GOTV..................................................
GOTV
, , .
, , .
, , .
, , .
, , .
, , .
, , .
PAGE
OF
Mailing Address
City
State
, , .
Zip Code
Purpose of Disbursement
Category/
Type
FEDERAL SHARE
M M / D D / Y Y Y Y
Date
LEVIN SHARE
, , .
, , .
, , .
Mailing Address
City
State
, , .
Zip Code
Purpose of Disbursement
Category/
Type
FEDERAL SHARE
M M / D D / Y Y Y Y
Date
LEVIN SHARE
, , .
Mailing Address
State
, , .
Zip Code
Purpose of Disbursement
FEDERAL SHARE
Category/
Type
LEVIN SHARE
, , .
M M / D D / Y Y Y Y
Date
, , .
, , .
FEDERAL SHARE
TOTAL AMOUNT
, , .
, , .
City
TOTAL AMOUNT
LEVIN SHARE
, , .
, , .
TOTAL This Period (last page for each line only)(Federal. share to 30(a)(i) and Levin share to 30(a)(ii))
FEDERAL SHARE
, , .
TOTAL This Period for the Levin Share
TOTAL AMOUNT
TOTAL AMOUNT
, , .
TOTAL AMOUNT
LEVIN SHARE
, , .
, , .
FEC Schedule H6 (Form 3X) Rev. 05/2016
COLUMN B
YEAR-TO-DATE
, , .
, , .
(b) Unitemized...................................
, , .
, , .
(c) Total..............................................
, , .
, , .
OTHER RECEIPTS.................................
, , .
, , .
3. TOTAL RECEIPTS..................................
(Add Lines 1c and 2)
, , .
, , .
2.
4.
TRANSFERS TO FEDERAL OR
ALLOCATION ACCOUNT
, , .
, , .
, , .
, , .
(c) GOTV...........................................
, , .
, , .
, , .
, , .
(e) Total..............................................
, , .
, , .
5.
OTHER DISBURSEMENTS....................
, , .
, , .
6.
TOTAL DISBURSEMENTS.....................
, , .
, , .
7.
, , .
, , .
8.
RECEIPTS...............................................
, , .
, , .
9.
SUBTOTAL .............................................
, , .
, , .
10.
DISBURSEMENTS..................................
, , .
, , .
11.
, , .
, , .
(from Line 3)
(From Line 6)
PAGE
FOR LINE NUMBER:
(check only one)
OF
1a
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions
or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (In Full)
A.
Full Name of Individual (Last, First, Middle Initial) or Full Organization Name
Memo Item
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
, , .
Aggregate Year-to-Date
B.
, , .
Full Name of Individual (Last, First, Middle Initial) or Full Organization Name
Memo Item
Mailing Address
City
State
Zip Code
, , .
Aggregate Year-to-Date
, , .
Full Name of Individual (Last, First, Middle Initial) or Full Organization Name
Memo Item
Mailing Address
City
State
Zip Code
, , .
Aggregate Year-to-Date
, , .
Full Name of Individual (Last, First, Middle Initial) or Full Organization Name
Memo Item
Date of Receipt
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
, , .
Aggregate Year-to-Date
, , .
, , .
Date of Receipt
M M / D D / Y Y Y Y
D.
Date of Receipt
M M / D D / Y Y Y Y
C.
Date of Receipt
, , .
PAGE
OF
4a
4c
4b
4d
Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions
or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.
NAME OF COMMITTEE (In Full)
A.
Memo Item
Date of Disbursement
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
, , .
Purpose of Disbursement
B.
Memo Item
Date of Disbursement
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
, , .
Purpose of Disbursement
C.
Memo Item
Date of Disbursement
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
, , .
Purpose of Disbursement
D.
Memo Item
Date of Disbursement
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
, , .
Purpose of Disbursement
E.
Memo Item
Date of Disbursement
M M / D D / Y Y Y Y
Mailing Address
City
State
Zip Code
, , .
Purpose of Disbursement
, , .
, , .
FEC Schedule LB (Form 3X) Rev. 05/2016