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FEC FORM 1
1. NAI\4E0F COI\/ll\/IITTEE (in full)
STATEMENT OF ORGANIZATION
(Checl< if name is changed) Example:if typing, type over the lines.
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RECEIVED
Office UssiOnli
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ADDRESS (number and street) (Checl< if address is changed)
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CITY
I STATE ZIP COIDE
COI\/ll\^ITTEE'S E-MA\L ADDRESS (Please provide only one e-mail address) (Checl< if address is changed)
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COIVIIVIITTEE'S WEB PAGE ADDRESS (URL) |\K)|U)|\0|M6|\
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F E C IDENTIFICATION N U M B E R
4.
IS THIS STATEI\/IENT
NEW (N)
OR
AI\/IENDED (A)
/ certify that I have examined this Statement and to the best of my knowledge and belief it is true, correct and complete.
Type or Print Name of Treasurer
( Y N O I H
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Signature of Treasurer
Date
NOTE: Submission of false, erroneous, or incomplete information may subject the person signing this Statement to the penalties of 2 U.S.C. 437g. ANY CHANGE IN INFORMATION SHOULD BE REPORTED WITHIN 10 DAYS. Office Use Only For further information contact: Federal Election Commission Toll Free 800-424-9530 Local 202-694-1100
FEC FORM 1
(Revised 02/2009)
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FEC Form 1 (Revised 02/2009) TYPE OF COIVIIVIITTEE
Page 2
Candidate Committee:
( ) LJ a
This committee is a principal campaign committee. (Complete the candidate information below.) This committee is an authorized committee, and is NOT a principal campaign committee. (Complete the candidate information below.)
1 1 I
Name of Candidate Candidate Party Affiliation
I I I I I I I I I
I I I
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Office Sought:
State House Senate President District
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This committee supports/opposes only one candidate, and is NOT an authorized committee.
I i i l l I I I I I I
Name of Candidate
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I I I I I I I I I I I I I I I I I I I I
Party Committee:
(d) Q ^l^'S committee is a (National, State or subordinate) committee of the (Democratic, Republican, etc.) Party.
Politicai Action Committee (PAC):
(e) This committee is a separate segregated fund, (identify connected organization on line 6.) Its connected organization is a: 0 0 Corporation Membership Organization Q (f) Q Q Corporation w/o Capital Stoci< Trade Association Q Q Labor Organization Cooperative
in addition, this committee is a Lobbyist/Registrant PAC.
This committee supports/opposes more than one Federal candidate, and is NOT a separate segregated fund or party committee, (i.e., nonconnected committee) Q In addition, this committee is a Lobbyist/Registrant PAC. in addition, this committee is a Leadership PAC. (Identify sponsor on line 6.)
Joint Fundraising Representative:
(g) (h) rl ^ This committee collects contributions, pays fundraising expenses and disburses net proceeds for two or more political committees/organizations, at least one of which is an authorized committee of a federal candidate. This committee collects contributions, pays fundraising expenses and disburses net proceeds for two or more political committees/organizations, none of which is an authorized committee of a federal candidate.
Committees Participating In Joint Fundraiser
1.
I I I I I I I I
J FEC ID number I FEC ID number FEC ID number
4. I I I I I I II
I I I I I I I
FEC ID number
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6.
FEC Form 1 (Revised 02/2009)
Page 3
Write or Type Committee Name
Name of Any Connected Organization, Affiliated Committee, Joint Fundraising Representative, or Leadership PAC Sponsor
Mailing Address
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CITY STATE
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ZIPCODE
Relationship: |*]| Connected Organization jjjAffiliated Committee Q Joint Fundraising Representative ^teadership PAC Sponsor
7.
Custodian of Records: identify by name, address (phone number ~ optional) and position of the person in possession of committee bool(S and records.
Full Name Mailing Address
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Title or Position CITY
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STATE ZiP CODE Telephone number
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8.
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Treasurer: List the name and address (phone number ~ optional) of the treasurer of the committee; and the name and address of any designated agent (e.g., assistant treasurer).
of^Trers^er Mailing Address
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CITY Title or Position
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ZIP CODE
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Telephone number
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FEC Form 1 (Revised 02/2009) Full Name of Designated Agent Mailing Address Page 4 . I I I I I I I i i i i i i i i i
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I I I I I I I I CITY
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I I I l"l I ZiP CODE
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Titie or Position
I I I I I I I I I I I I I I I I I I I I I Telephone number I i i I -1 i i I -1 i i i I
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II 9. Banks or Other Depositories: List ail banl<s or other depositories in which the committee deposits funds, holds accounts, rents safety deposit boxes or maintains funds. Name of Banl<, Depository, etc.
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Mailing Address
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CITY Name of Banl<, Depository, etc. STATE ZiP CODE
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Mailing Address
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ZIP CODE
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Federal Election Commission ENVELOPE REPLACEMENT PAGE FOR INCOMING DOCUMENTS The FEC added this page to the end of this filing to indicate how it was received. Date of Receipt
Hand Delivered Postmarked
p ^ ^ U S P S First Class Mail
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Postmarked (R/C) I I I USPS Registered/Certified Postmarked I USPS Priority Mail Delivery Confirmation or Signature Confirmation Label I I I I USPS Express Mail I Postmark Illegible No Postmark I Ovemight Delivery Service (Specify): Shipping Date Next Business Day Delivery I I I Received from House Records & Registration Office Received from Senate Public Records Office Date of Receipt I I I Received from Electronic Filing Office I Other (Specify): Date of Receipt or Postmarked Date of Receipt Date of Receipt I Postmarked I
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PREPARER (3/2005)
DATE PREPARED
