Free Pacr10.indd - Wyoming

STATEMENT OF RECEIPTS ONLY
POLITICAL ACTION COMMITTEE W.S. 22-25-106 A committee formed before any primary, general or special election is required to file a statement of receipts at least seven (7) days before the election current to any day from the eighth day up to the fourteenth day before the election. The committee shall also file a statement of receipts and expenditures within ten (10) days after a primary, general or special election. Reports shall be filed with the appropriate filing office. A committee formed after an election to defray campaign expenses incurred during a previous election, and any ongoing committee, shall file an itemized statement of receipts and expenditures on December 31 of each odd-numbered year and shall continue to make the reports until the committee terminates. The general rule is that a political action committee should note and keep track of all campaign contributions no matter how small. The law only requires you to itemize on this form contributions (receipts) totaling $25.00 or more. However, please keep in mind that if you receive $10.00 from a contributor who then later gives you $20.00, you must report the total $30.00 contribution on this form. A violation of the campaign reporting provisions of the Wyoming Election Code may constitute a misdemeanor and be punishable by not more than six (6) months imprisonment in a county jail, a fine of not more than $1,000.00 or both. W.S. 22-26-112.

Filing Deadlines Primary Election: *Receipts only - before Primary Election - August 10, 2010 (at least 7 days before Primary Election.) General Election: *Receipts only - before General Election - October 26, 2010 (at least 7 days before General Election.) Special Election: *Receipts only - (at least seven (7) days before the election.) Initiative or Referendum Petition Drive: *Receipts and Expenditures within ten (10) days after petition is filed with the Secretary of State. *Receipts and Expenditures due within ten (10) days after the General Election - November 14, 2008. Filing Office County Clerk - Supporting or opposing candidates for district attorney, county and municipal offices, magistrates, school and community college district trustees or local ballot proposition. Mail to local County Clerk's Office. Contact information can be accessed on our website under Elections at http://soswy.state.wy.us

This form can be accessed on the Secretary of State's website at: http://soswy.state.wy.us/Forms/FormsFiling.aspx
4/2009 pacr10

For Office Use Only

RECEIPTS REPORT
Statement covers period: From: To:

Type of Report: (Check One) Pre-Primary Receipts Report - August 10, 2010 Pre-General Receipts Report - October 26, 2010 Pre-Special Election Amendment Check here if you are terminating the committee with this report
NOTE: A committee must have retired all debts before terminating. W.S. 22-25-106 (b)(iii)

Name of Committee Mailing Address City

State

Zip

Phone

Summary for this filing period: A. Receipts 1. 2. 3. Contributions from Individuals (page 2) Contributions from PACs (page 3)

If you have no receipts to report for this filing period check here and sign below.

$ $ $ $ $ $ $ $ $

Contributions from Political Parties (page 3)

4. Contributions from Corporations, Organizations, Associations, etc. (page 4) 5. 6. 7. 8. Anonymous Contributions (page 4) In-Kind Contributions (page 5) Loans (page 5) Unitemized receipts (page 5)
(Unitemized receipts are defined as contributions less than $25)

B.

Total Receipts for this Filing Period (Sum of A1-A8)

I certify that I have examined this statement, and to the best of my knowledge and belief, it is true, correct and complete. Signature of Chairman (Required) Signature of Treasurer (Required)

Chairman E-mail Address

Treasurer E-mail Address

Date

Date

1

Contributions from Individuals
(Contributions from corporations, unions, partnerships and associations are prohibited. Contributions from sole proprietorships are legal, but must be identified as such.)

Name

Address
(City, State & Zip)

Date

Amount

2

Contributions from Political Action Committees
Name (Identify by full name) Address
(City, State & Zip)

Date

Amount

Contributions from Political Party Central Committees
Name Address
(City, State & Zip)

Date

Amount

3

Contributions from Corporations, Organizations, Associations, etc.
These groups are prohibited from making contributions to candidates and political parties. However, these groups may make contributions to support or oppose a ballot proposition or an initiative or referendum petition drive. Name Address
(City, State & Zip)

Date

Description of Contribution

Value or Amount

Anonymous Contributions
Anonymous contributions are those contributions whose orgins cannot be determined, i.e., "pass the hat" contributions. An anonymous contribution does not mean a contributor may donate to the candidate or PAC with the understanding the contributor's name will not be reported. Event Date Amount

I do not know, nor can I ascertain, the origin of the above anonymous contributions.

Chairman or Treasurer 4

In-Kind Contributions
Name Address
(City, State & Zip)

Date

Description of Contribution

Value or Amount

Loans/Obligations

Date

Amount

Unitemized Receipts
(Receipts under $25.00. For example, you have a chili dinner. Tickets are $10.00 each and you sell 500 tickets. You may report these in aggregate here by reporting $5,000.00.) Event (if applicable) Date Amount

5