Free 46413.pdf - Indiana

REGULAR PARTY COMMITTEE STATEMENT OF ORGANIZATION
State Form 46413 (R4/11-05) Indiana Election Commission (IC 3-9-1-3 and IC 3-9-1-4)

(CFA-3)

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



SECTION A.

COMMITTEE INFORMATION: Fill in all applicable boxes as fully and accurately as possible.
3. Acronym or Abbreviated Name (if any)

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) ( ) Yes No

8. Telephone ( )

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

10. Is this committee registered with the Federal Election Committee? 11. Type of Regular Party Committee (Check one) National State Congressional District County

City

Town

12. Party Affiliation (Check one) Democratic Libertarian Republican Other ____________________________________ 14. E-mail Address (Optional)

13. Chairperson's Name

Check if this is a new chairperson

15. Mailing Address

Check if this is a new address

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

17. Telephone (Evening) ( )

18. Treasurer's Name

Check if this is a new treasurer

20. Mailing Address

Check if this is a new address

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

22. Telephone (Evening) ( )

23. Custodian of Records' Name

Check if this is a new custodian

25. Mailing Address

Check if this is a new address

26. Telephone (Day)

27. Telephone (Evening)

( ) ( ) 28. 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

29. 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

30. 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. 31. 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. 32. Typed or Printed Name of Chairperson Signature of Chairperson Date (MM­DD­YY)

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 Regular Party Committees (central committees only or the national committee of a political party (IC 3-5-2-42)) when organizing 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 46413 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. Check if this is a new name. ITEM 3: Enter acronym or abbreviated name. 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 10: Check "Yes" if the committee is registered with the Federal Election Commission (FEC). ITEM 11: Indicate the type of regular party committee by checking the appropriate box. ITEM 12: Enter the party affiliation. ITEM 13: 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 18: 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 23: 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 28: 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 29: APPOINTMENT OF TREASURER: This section must be completed in its entirety by the committee chairperson. ITEM 30: 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 30. ITEM 32: 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) 622-4941 or at the e-mail address [email protected] for further information.

SPECIAL INSTRUCTIONS FOR CERTAIN POLITICAL ACTION COMMITTEES
This instruction applies to a political action committee which is (1) required to file with the Election Division; and (2) received more than $50,000 in contributions since the close of the previous reporting period. This form must be filed electronically with the Election Division. Contact 1-800-6224941 for more information. ITEM 6: Enter the committee 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 began to operate.