Free Form 8872 (Rev. November 2002) - Federal

Form

8872
For the period beginning Check applicable boxes: Name of organization

(November 2002)
Department of the Treasury Internal Revenue Service

Political Organization Report of Contributions and Expenditures
See Seperate instructions.
,20 Intial report Change of address and ending

OMB No. 1545-1696

A B 1 2

, 20

Amended report Final report Employer identification number

Mailing address (P.O. Box or number, street, and room or suite number) City or town, state, and ZIP code

3

E-mail address of organization 5b Custodian's address

4 Date organization was formed

5a Name of custodian of records

6a Name of contact person

6b Contact person's address

7

Business address of organization (if different from mailing address shown above). Number, street, and room or suite number City or town, state, and ZIP code

8

Type of report (check only one box) f a b c d e First quarterly report (due by April 15) Second quarterly report (due by July 15) Third quarterly report (due by October 15) Year-end report (due by January 31) h Mid-year report (Non-election year only-due by July 31) Post-general election report (due by the 30th day after general election) (1) Date of election: (2) For the state of: g Monthly report for the month of: (due by the 20th day following the month shown above, except the December report, which is due by January 31) Pre-election report (due by the 12th or 15th day before the election) (1) Type of election: (2) Date of election: (3) For the state of:

9 10

Total amount of reported contributions (total from all attached Schedules A) Total amount of reported expenditures (total from all attached Schedules B)

9 10

Sign Here

Under penalties of perjury, I declare that I have examined this report, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete.

Signature of authorized official For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 30406G

Date
Form

8872

(11-2002)

Form 8872 (11-2002)

Schedule A

Itemized Contributions

Name of organization Contributor's name, mailing address and ZIP code Name of contributor's employer Contributor's occupation

Schedule A page of Employer identification number Amount of contribution

Contributor's name, mailing address and ZIP code

Aggregate contributions year-to-date $ Name of contributor's employer Contributor's occupation

$ Date of contribution Amount of contribution

Contributor's name, mailing address and ZIP code

Aggregate contributions year-to-date $ Name of contributor's employer Contributor's occupation

$ Date of contribution Amount of contribution

Contributor's name, mailing address and ZIP code

Aggregate contributions year-to-date $ Name of contributor's employer Contributor's occupation

$ Date of contribution Amount of contribution

Contributor's name, mailing address and ZIP code

Aggregate contributions year-to-date $ Name of contributor's employer Contributor's occupation

$ Date of contribution Amount of contribution

Contributor's name, mailing address and ZIP code

Aggregate contributions year-to-date $ Name of contributor's employer Contributor's occupation

$ Date of contribution Amount of contribution

Contributor's name, mailing address and ZIP code

Aggregate contributions year-to-date $ Name of contributor's employer Contributor's occupation

$ Date of contribution Amount of contribution

Contributor's name, mailing address and ZIP code

Aggregate contributions year-to-date $ Name of contributor's employer Contributor's occupation

$ Date of contribution Amount of contribution

Contributor's name, mailing address and ZIP code

Aggregate contributions year-to-date $ Name of contributor's employer Contributor's occupation

$ Date of contribution Amount of contribution

Aggregate contributions year-to-date

$ Date of contribution $ $
Form

Subtotal of contributions reported on this page only. Enter here and also include this amount in the total on line 9 of Form 8872

8872

(11-2002)

Form 8872 (11-2002)

Schedule B

Itemized Expenditures

Name of organization Recipient's name, mailing address and ZIP code Name of recipient's employer

Schedule B page of Employer identification number Amount of expenditure $ Date of expenditure

Recipient's occupation

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Name of recipient's employer

Amount of expenditure $ Date of expenditure

Recipient's occupation

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Name of recipient's employer

Amount of expenditure $ Date of expenditure

Recipient's occupation

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Name of recipient's employer

Amount of expenditure $ Date of expenditure

Recipient's occupation

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Name of recipient's employer

Amount of expenditure $ Date of expenditure

Recipient's occupation

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Name of recipient's employer

Amount of expenditure $ Date of expenditure

Recipient's occupation

Purpose of expenditure

Subtotal of expenditures reported on this page only. Enter here and also include this amount in the total on line 10 of Form 8872

$
Form

8872

(11-2002)