Free Report of Receipts and Disbursements - Federal

FEC FORM 3
1. NAME OF COMMITTEE (in full)

REPORT OF RECEIPTS AND DISBURSEMENTS
For An Authorized Committee
Office Use Only

TYPE OR PRINT

Example: If typing, type over the lines.

12FE4M5

ADDRESS (number and street)


2.

Check if different than previously reported. (ACC)

FEC IDENTIFICATION NUMBER

CITY

STATE NEW (N) OR

ZIP CODE STATE DISTRICT

C
4. TYPE OF REPORT (Choose One)
(a) Quarterly Reports:
April 15 Quarterly Report (Q1) July 15 Quarterly Report (Q2) October 15 Quarterly Report (Q3) January 31 Year-End Report (YE)

3. IS THIS REPORT

AMENDED (A)

(b) 12-Day PRE-Election Report for the: Election on Primary (12P) Convention (12C)
M M / D D / Y

General (12G) Special (12S)
Y Y Y

Runoff (12R)

in the State of

(c) 30-Day POST-Election Report for the: General (30G) Election on
M M / D D / Y

Runoff (30R)
Y Y Y

Special (30S) in the State of

Termination Report (TER)

M

M

/

D

D

/

Y

Y

Y

Y

M

M

/

D

D

/

Y

Y

Y

Y

5.

Covering Period

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
M M / D D / Y Y Y Y

Signature of Treasurer

Date

NOTE: Submission of false, erroneous, or incomplete information may subject the person signing this Report to the penalties of 2 U.S.C. §437g.

Office Use Only
FE5AN018

FEC FORM 3
(Revised 02/2003)









FEC Form 3 (Revised 02/2003) Write or Type Committee Name

of Receipts and Disbursements

SUMMARY PAGE

Page 2

M

M

/

D

D

/

Y

Y

Y

Y

M

M

/

D

D

/

Y

Y

Y

Y

Report Covering the Period:

From:

To:

COLUMN A This Period
6. 7. 8. 9. Net Contributions (other than loans) (a) Total Contributions (other than loans) (from Line 11(e)).... (b) Total Contribution Refunds (from Line 20(d)).................................. (c) Net Contributions (other than loans) (subtract Line 6(b) from Line 6(a))...... Net Operating Expenditures (a) Total Operating Expenditures (from Line 17)...................................... (b) Total Offsets to Operating Expenditures (from Line 14)................ (c) Net Operating Expenditures (subtract Line 7(b) from Line 7(a))...... Cash on Hand at Close of Reporting Period (from Line 27) ................ . Debts and Obligations Owed TO the Committee (Itemize all on Schedule C and/or Schedule D)................

COLUMN B Election Cycle-to-Date

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10. Debts and Obligations Owed BY the Committee (Itemize all on Schedule C and/or Schedule D)................

For further information contact: Federal Election Commission 999 E Street, NW Washington, DC 20463 Toll Free 800-424-9530 Local 202-694-1100

FE5AN018

DETAILED SUMMARY PAGE

FEC Form 3 (Revised 12/2003) Write or Type Committee Name

of Receipts

Page 3

M

M

/

D

D

/

Y

Y

Y

Y

M

M

/

D

D

/

Y

Y

Y

Y

Report Covering the Period:

From:

To:

I. RECEIPTS
11. CONTRIBUTIONS (other than loans) FROM: (a) Individuals/Persons Other Than Political Committees (i) Itemized (use Schedule A)........... (ii) Unitemized.................................... (iii) TOTAL of contributions from individuals .......................

COLUMN A Total This Period

COLUMN B Election Cycle-to-Date

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(b) Political Party Committees ................ . (c) Other Political Committees (such as PACs)................................... (d) (e) The Candidate.................................... TOTAL CONTRIBUTIONS (other than loans) (add Lines 11(a)(iii), (b), (c), and (d)) . .

12. TRANSFERS FROM OTHER AUTHORIZED COMMITTEES.................... 13. LOANS: (a) Made or Guaranteed by the Candidate ........................................... . (b) All Other Loans.................................. . (c) TOTAL LOANS (add Lines 13(a) and (b))....................

14. OFFSETS TO OPERATING EXPENDITURES (Refunds, Rebates, etc.)............................ 15. OTHER RECEIPTS (Dividends, Interest, etc.)........................... 16. TOTAL RECEIPTS (add Lines 11(e), 12, 13(c), 14, and 15) (Carry Total to Line 24, page 4) ........... .

FE5AN018





DETAILED SUMMARY PAGE
FEC Form 3 (Revised 02/2003)

of Disbursements

Page 4

II. DISBURSEMENTS

COLUMN A Total This Period

COLUMN B Election Cycle-to-Date

17. OPERATING EXPENDITURES .................... . 18. TRANSFERS TO OTHER AUTHORIZED COMMITTEES..................... 19. LOAN REPAYMENTS: (a) Of Loans Made or Guaranteed by the Candidate ................................ . (b) Of All Other Loans.............................. (c) TOTAL LOAN REPAYMENTS (add Lines 19(a) and (b)).....................

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20. REFUNDS OF CONTRIBUTIONS TO: (a) Individuals/Persons Other Than Political Committees.................. (b) Political Party Committees ................. . (c) Other Political Committees (such as PACs).................................... (d) TOTAL CONTRIBUTION REFUNDS (add Lines 20(a), (b), and (c))............. .

21. OTHER DISBURSEMENTS......................... 22. TOTAL DISBURSEMENTS (add Lines17,18,19(c),20(d),and21)

III. CASH SUMMARY
23. CASH ON HAND AT BEGINNING OF REPORTING PERIOD...............................................



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24 TOTAL RECEIPTS THIS PERIOD (from Line 16, page 3).....................................................

25. SUBTOTAL (add Line 23 and Line 24)..................................................................................

26. TOTAL DISBURSEMENTS THIS PERIOD (from Line 22)...................................................... 27. CASH ON HAND AT CLOSE OF REPORTING PERIOD (subtract Line 26 from Line 25)..............................................................................................

FE5AN018

SCHEDULE A (FEC Form 3) ITEMIZED RECEIPTS

Use separate schedule(s) for each category of the Detailed Summary Page

FOR LINE NUMBER: (check only one)
11a 12 11b 13a

PAGE
11c 13b

OF
11d 14 15

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)

Full Name (Last, First, Middle Initial)

A.

Mailing Address City State Zip Code

Date of Receipt
M M / D D / Y Y Y Y

FEC ID number of contributing federal political committee. Name of Employer Receipt For: Primary Other (specify)

C
Occupation Election Cycle-to-Date

Amount of Each Receipt this Period

, , , .
Date of Receipt
M M / D D /

,

.

General

Full Name (Last, First, Middle Initial)

B.

Mailing Address City FEC ID number of contributing federal political committee. Name of Employer Receipt For: Primary Other (specify) State Zip Code

Y

Y

Y

Y

C
Occupation Election Cycle-to-Date

Amount of Each Receipt this Period

, , , .
Date of Receipt
M M / D D /

,

.

General

Full Name (Last, First, Middle Initial)

C.

Mailing Address City FEC ID number of contributing federal political committee. Name of Employer Receipt For: Primary Other (specify) State Zip Code

Y

Y

Y

Y

C
Occupation Election Cycle-to-Date

Amount of Each Receipt this Period

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,

.

General

SUBTOTAL of Receipts This Page (optional) ............................................................................ TOTAL This Period (last page this line number only) ...............................................................

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FEC Schedule A (Form 3) (Revised 02/2009)

SCHEDULE B (FEC Form 3) ITEMIZED DISBURSEMENTS

Use separate schedule(s) for each category of the Detailed Summary Page

FOR LINE NUMBER: (check only one)
17 20a 18 20b

PAGE
19a 20c

OF
19b 21

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)

Full Name (Last, First, Middle Initial)

A.
Mailing Address City Purpose of Disbursement Candidate Name House Senate President State: District: Full Name (Last, First, Middle Initial) Office Sought: Disbursement For: Primary Other (specify) Category/ Type General State Zip Code

Date of Disbursement
M M / D D / Y Y Y Y

Amount of Each Disbursement this Period

,

,

.

B.
Mailing Address City Purpose of Disbursement Candidate Name Office Sought: House Senate President District: Disbursement For: Primary Other (specify) Category/ Type General State Zip Code

Date of Disbursement
M M / D D / Y Y Y Y

Amount of Each Disbursement this Period

,

,

.

State:

Full Name (Last, First, Middle Initial)

C.
Mailing Address City Purpose of Disbursement Candidate Name Office Sought: House Senate President District: Disbursement For: Primary Other (specify) Category/ Type General State Zip Code

Date of Disbursement
M M / D D / Y Y Y Y

Amount of Each Disbursement this Period

,

,

.

State:

SUBTOTAL of Disbursements This Page (optional) .................................................................. TOTAL This Period (last page this line number only) ...............................................................

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FE5AN018

FEC Schedule B (Form 3) (Revised 02/2009)

SCHEDULE C (FEC Form 3) LOANS
NAME OF COMMITTEE (In Full)

PAGE Use separate schedule(s) for each category of the Detailed Summary Page FOR LINE NUMBER: (check only one)

OF
13a 13b



LOAN SOURCE Full Name (Last, First, Middle Initial)

Mailing Address City State ZIP Code

Election: Primary General Other (specify)

Original Amount of Loan

Cumulative Payment To Date

Balance Outstanding at Close of This Period

,
TERMS
M M / D D

,
Date Incurred
/ Y Y

.
Y Y M M /

,
D D /

,

Y Y Y Y

.
Interest Rate

,


,


.
Secured:

Date Due

.

% (apr)


Yes

No

List All Endorsers or Guarantors (if any) to Loan Source
1. Full Name (Last, First, Middle Initial) Mailing Address
Name of Employer Occupation Amount Guaranteed Outstanding: Name of Employer Occupation Amount Guaranteed Outstanding: Name of Employer Occupation Amount Guaranteed Outstanding: Name of Employer Occupation Amount Guaranteed Outstanding:



City

State

ZIP Code

,

,

.

2. Full Name (Last, First, Middle Initial) Mailing Address

City

State

ZIP Code

,

,

.

3. Full Name (Last, First, Middle Initial) Mailing Address

City

State

ZIP Code

,

,

.

4. Full Name (Last, First, Middle Initial) Mailing Address

City

State

ZIP Code

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. . .

SUBTOTALS This Period This Page (optional) ................................................................ . TOTALS This Period (last page in this line only).............................................................

Carry outstanding balance only to LINE 3, Schedule D, for this line. If no Schedule D, carry forward to appropriate line of Summary.
FE5AN018



FEC Schedule C (Form 3) (Revised 02/2003)

SCHEDULE C-1 (FEC Form 3) LOANS AND LINES OF CREDIT FROM LENDING INSTITUTIONS
Federal Election Commission, Washington, D.C. 20463

Supplementary for Information found on Page of Schedule C

NAME OF COMMITTEE (In Full)

FEC IDENTIFICATION NUMBER

C
LENDING INSTITUTION (LENDER) Full Name Mailing Address Amount of Loan Interest Rate (APR)

,

,

.
M M / D D M M / D D


/ Y Y Y

.
Y

%
Y

Date Incurred or Established State Zip Code Date Due

/

Y

Y

Y

City

M

M

/

D

D

/

Y

Y

Y

Y

A. Has loan been restructured? B. If line of credit, Amount of this Draw:

No

Yes

If yes, date originally incurred

,

,

.

Total Outstanding Balance:

,

,

.

C. Are other parties secondarily liable for the debt incurred? No Yes (Endorsers and guarantors must be reported on Schedule C.) D. Are any of the following pledged as collateral for the loan: real estate, personal property, goods, negotiable instruments, certificates of deposit, chattel papers, stocks, accounts receivable, cash on deposit, or other similar traditional collateral? No Yes If yes, specify: What is the value of this collateral?

,

,

.

Does the lender have a perfected security interest in it? No Yes E. Are any future contributions or future receipts of interest income, pledged as collateral for the loan? No Yes If yes, specify: What is the estimated value?

,

,

.

A depository account must be established pursuant to 11 CFR 100.82(e)(2) and 100.142(e)(2). Date account established:
M M / D D / Y Y Y Y

Location of account: Address: City, State, Zip:

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 H. Attach a signed copy of the loan agreement. I.

DATE
M M / D D / Y Y Y Y

TO BE SIGNED BY THE LENDING INSTITUTION: I. To the best of this institution's knowledge, the terms of the loan and other information regarding the extension of the loan are accurate as stated above. I. The loan was made on terms and conditions (including interest rate) no more favorable at the time than those imposed for I similar extensions of credit to other borrowers of comparable credit worthiness. III. This institution is aware of the requirement that a loan must be made on a basis which assures repayment, and has complied with the requirements set forth at 11 CFR 100.82 and 100.142 in making this loan. DATE
M M / D D / Y Y Y Y

AUTHORIZED REPRESENTATIVE Typed Name Signature

Title

FE5AN018

FEC Schedule C-1 (Form 3) (Revised 02/2003)

SCHEDULE D (FEC Form 3) DEBTS AND OBLIGATIONS
Excluding Loans
NAME OF COMMITTEE (In Full)

(Use separate schedule(s) for each numbered line)

PAGE FOR LINE NUMBER: (check only one)

OF
9 10

A. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Nature of Debt (Purpose):

Mailing Address City State Zip Code

Outstanding Balance Beginning This Period

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.
Payment This Period Outstanding Balance at Close of This Period

Amount Incurred This Period

.

,

,

.

,

,

.

B. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Nature of Debt (Purpose):

Mailing Address City State Zip Code

Outstanding Balance Beginning This Period

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.
Payment This Period Outstanding Balance at Close of This Period

Amount Incurred This Period

.

,

,

.

,

,

.

C. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Nature of Debt (Purpose):

Mailing Address City State Zip Code

Outstanding Balance Beginning This Period

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.
Payment This Period Outstanding Balance at Close of This Period

Amount Incurred This Period

.

,

,

.


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1) SUBTOTALS This Period This Page (optional)................................................................... 2) TOTALS This Period (last page this line number only)...................................................... 3) TOTAL OUTSTANDING LOANS from Schedule C (last page only) ................................. . 4) ADD 2) and 3) and carry forward to appropriate line of Summary Page (last page only)







FEC Schedule D (Form 3) (Revised 02/2003)

FE5AN018

FEC FORM 3Z (File with Form 3) CONSOLIDATION REPORT OF RECEIPTS AND DISBURSEMENTS
(To Be Used By A Principal Campaign Committee)
Name of Principal Campaign Committee (In Full)

Report Covering Period: From:
M M / D D / Y Y Y Y

To:
M M / D D / Y Y Y Y

Committee Name

(a) Line No. 11(a) Total Contributions From Indiv./Persons Other Than Political Committees

(b) Line No. 11(b) Total Contributions From Political Party Committees

A BColumnTotalLastPageOnly.............................................................................................................
(c) Line No. 11(c) Total Contributions From Other Political Committees (d) Line No. 11(d) Total Contributions From The Candidate (e) Line No. 11(e) Total Contributions (f) Line No. 12 Total Transfers From Other Authorized Committees (g) Line No. 13(a) Total Loans Made or Guaranteed by the Candidate (h) Line No. 13(b) Total All Other Loans

A B
(i) Line No. 13(c) Total Loans (j) Line No. 14 Total Offsets to Operating Expenditures (k) Line No. 15 Total Other Receipts (l) Line No. 16 Total Receipts (m) Line No. 17 Total Operating Expenditures (n) Line No. 18 Total Transfers to Other Authorized Committees

A B
(o) Line No. 19(a) Total Loan Repayments of Loans Made or Guaranteed by The Candidate (p) Line No. 19(b) Total Loan Repayments of All Other Loans (q) Line No. 19(c) Total Loan Repayments (r) Line No. 20(a) Total Contribution Refunds to Individuals/Persons (s) Line No. 20(b) Total Contribution Refunds to Political Party Committees (t) Line No. 20(c) Total Contribution Refunds to Other Political Committees

A B
(u) Line No. 20(d) Total Contribution Refunds (v) Line No. 21 Total Other Disbursements (w) Line No. 22 Total Disbursements (x) Line No. 23 Cash on Hand Beginning of Reporting Period (y) Line No. 27 Cash on Hand Close of Reporting Period (z) Line No. 9 Debts & Obligations Owed TO the Committee

A B
(aa) Line No. 10 Debts & Obligations Owed BY the Committee (bb) Line No. 6(c) Net Contributions (cc) Line No. 7(c) Net Operating Expenditures

A B

FE5AN018

FECForm3Z(Revised02/2003)