Free 28251.pdf - Indiana

POLITICAL ACTION COMMITTEE OR LEGISLATIVE CAUCUS COMMITTEE STATEMENT OF ORGANIZATION
State Form 28251 (R8/11-05) Indiana Election Commission (IC 3-9-1-3 and IC 3-9-1-4)

(CFA-2)

PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK. SEE INSTRUCTIONS ON REVERSE SIDE

FILE NUMBER
1. IS THIS AN AMENDMENT? No Yes If Yes, please enter the file number in this box
Check if this is a new name Check if this is a new address 3. Acronym or Abbreviated Name (if any)

SECTION A.

COMMITTEE INFORMATION: Fill in all applicable boxes as fully and accurately as possible.

2. Full Name of Committee (Do not abbreviate)

4. Mailing Address (Address where all campaign finance correspondence is received)

5. E-mail Address (Optional)

6. City

State

ZIP Code

7. FAX (Optional) ( ) No

8. Telephone ( )

9. Committee Organization Date
(MM-DD-YY)

10. Is this committee registered with the Federal Election Committee?

Yes

11. Is this committee a "Legislative Caucus Committee" under IC 3-5-2-27.3?

Yes

No

12. State the purpose of the committee and on which issues the committee expects to focus. 13. Name and address of any connected, affiliated, sponsoring organization, corporation, 14. Is this committee supporting a political party's entire ticket? Yes group, or individual. Democratic Libertarian Check party affiliation if applicable: Other

No Republican

_____________________________________________________

15. If supporting or opposing a public question, state both the subject of the question AND the committee position.

16. Chairperson's Name

Check if this is a new chairperson

17. E-mail Address (Optional)

18. Mailing Address

Check if this is a new address

19. Telephone (Day) ( ) 22. E-mail Address (Optional)

20. Telephone (Evening) ( )

21. Treasurer's Name

Check if this is a new treasurer

23. Mailing Address

Check if this is a new address

24. Telephone (Day) ( ) 27. E-mail Address (Optional)

25. Telephone (Evening) ( )

26. Custodian of Records' Name

Check if this is a new custodian

28. Mailing Address

Check if this is a new address

29. Telephone (Day)

30. Telephone (Evening)

( ) ( ) 31. Bank or Other Depositories (List all banks or other depositories in which the committee deposits funds, holds accounts, rents safety deposit boxes or maintains funds.)

SECTION B.

APPOINTMENT OF TREASURER (IC 3-9-1-14)
Signature of the Committee Chairperson

32. I, as Chairperson of the foregoing committee, Person Appointed Treasurer appoint the following person as Treasurer of the Committee.

SECTION C.

ACCEPTANCE OF APPOINTMENT (IC 3-9-1-15)
FOR OFFICE USE ONLY

33. I give notice that I accept the duties and responsibilities of Treasurer of this Committee. I am not the chairperson of any other campaign finance committee. 34. Typed or Printed Name of Treasurer Signature of Treasurer Date (MM­DD­YY)

SECTION D.

CERTIFICATION OF STATEMENT

I certify that I am the duly appointed Chairperson of the Committee and have examined this statement. To the best of my knowledge and belief it is true, correct and complete. 35. Typed or Printed Name of Chairperson Signature of Chairperson Date (MM-DD­YY)
Warning: Any information contained in this statement may not be copied for sale or used for any commercial purpose. (IC 3-9-4-5) State law requires that any change in this information must be reported within 10 days of the change. (IC 3-9-1-10) A person who knowingly files a fraudulent report commits a Class D felony. (IC 3-14-1-13) A person who fails to file a complete or accurate report as required by the Indiana Campaign Finance Law commits a Class B misdemeanor (IC 3-14-1-14) and may be subject to civil penalties. (IC 3-9-4-16, IC 3-9-4-17, and IC 3-9-4-18)

INSTRUCTIONS FOR COMPLETING THIS FORM
This form is to be used by Political Action Committees (PACs) or Legislative Caucus Committees as required by IC 3-9-1-3 and IC 3-9-1-4. The preparer should type or print legibly in black ink all information on this form. If more space is needed, please attach additional sheets. All previous versions of State Form 28251 are obsolete and cannot be used. (IC 3-5-4-8) State law requires that any changes on this form must be reported WITHIN 10 DAYS OF THE CHANGE. ITEM 1: IS THIS AN AMENDMENT? Check "No" if organizing for the first time. Check "Yes" if updating information. If "Yes," enter the previously assigned Election Division or County Election Board file number in the box titled "FILE NUMBER." ITEM 2: Enter full name of the Committee. Do no abbreviate. For example: Widget Manufacturers Political Action Committee; Indiana House Federalist Caucus. Check if this is a new name. ITEM 3: Enter acronym or abbreviated name. For example: W-PAC; IHFC. ITEM 4: Enter the mailing address of the committee. All correspondence with the committee relative to filings under the Campaign Finance Act will be mailed to this address, unless specified otherwise. Check if this is a new address. ITEM 13: Enter the name and address of any connected, affiliated, sponsoring organization, corporation, group or individual. For example: If the Association of Widget Manufacturers forms W-PAC, then the Association should be listed here. If one or two widget manufacturers form a PAC, then both manufacturers should be listed. ITEM 15: State both the public question and the committee's position. For example: A public question might be "Should horses be allowed to buy lottery tickets on riverboats?" The committee's position is to oppose this question. ITEM 16: CHAIRPERSON INFORMATION: Enter the name, mailing address (if known, include ZIP Code+4), day and evening telephone numbers (including area code) of the committee chairperson. Note: The chairperson may not be the treasurer of any other campaign finance committee. Check if this is a new chairperson or new information. ITEM 21: TREASURER INFORMATION: Enter the name, mailing address (if known, include ZIP Code+4), day and evening telephone numbers (including area code) of the committee treasurer. The treasurer must be a U.S. citizen and may not be the chairperson of any other campaign finance committee. The treasurer's duties and responsibilities are discussed in detail in the Instruction Manual for the Indiana Campaign Finance Act (current edition). Check if this is a new treasurer or new information. ITEM 26: CUSTODIAN OF RECORDS: Enter the name, mailing address (if known, include ZIP Code+4), title (bookkeeper, accountant, etc.), day and evening telephone numbers (included area code) of the person who has actual possession of the committee's bookkeeping records. Check if this is a new custodian or new information. ITEM 31: Enter the name of all banks or other depositories in which the committee deposits funds, holds accounts, rents safety deposit boxes or maintains funds. All funds of a committee must be segregated from and MAY NOT be commingled with the person funds of the officer, members, or associates of the committee. (IC 3-9-2-9) ITEM 32: APPOINTMENT OF TREASURER: This section must be completed in its entirety by the committee chairperson. ITEM 33: ACCEPTANCE OF APPOINTMENT: The treasurer must provide that individual's written signature verifying acceptance of the duties and responsibilities as committee treasurer. It is not necessary for an assistant treasurer to complete ITEM 33. ITEM 35: The chairperson must enter that individual's typed or printed name, written signature and date signed in this section. NOTICE: Read and understand the warning printed on the other side of this form. Contact the Indiana Election Division or your County Election Board if you have any questions.

ITEM 5. COMMITTEES FILING WITH THE INDIANA ELECTION DIVISION ONLY: Committees that file campaign finance reports with the Indiana Election Division and wish to file these reports electronically may contact the Election Division at (800) 622-4941or at the e-mail address [email protected] for further information.
ITEM 6: Enter the city, state and ZIP Code. (If known, include ZIP Code+4.) ITEM 8: Enter the committee telephone number, including area code. (This will typically be the committee's day telephone number.) ITEM 9: Enter the date when the committee was organized. This may be the date the committee solicited or accepted contributions, or made expenditures. ITEM 10: Check "Yes" if the committee is registered with the Federal Election Commission (FEC). ITEM 12: State the purpose of the committee and on which issues the committee expects to focus. For example: A PAC may state, "This committee is formed as a means for members of the Association of Widget Manufacturers to impact the political process especially in the area of state regulation of widgets and other concerns relating to business."