Fec 3X Form – Fill Out and Use This PDF

Fec 3X Form – Fill Out and Use This PDF

Form Preview Example

Fec 3X Form PDF Details

Form Preview Example

Fec 3X Form isn’t the one you’re looking for?

Fec 3X Form PDF Details

Form Preview Example

Fec 3X Form isn’t the one you’re looking for?

Related Documents

FEC

FORM 3X

REPORT OF RECEIPTS AND DISBURSEMENTS

For Other Than An Authorized Committee

Office Use Only

1. NAME OF		TYPE OR PRINT ▼	Example: If typing, type
	COMMITTEE (in full)		over the lines.

12FE4M5

ADDRESS (number and street)

▼

Check if different than previously reported. (ACC)

2.FEC IDENTIFICATION NUMBER ▼

CITY ▼

3. IS THIS REPORT

STATE ▼	ZIP CODE ▼
NEW	AMENDED
(N) OR	(A)

4. TYPE OF REPORT

(Choose One)

(a)Quarterly Reports:

April 15

Quarterly Report (Q1)

July 15

Quarterly Report (Q2)

October 15

Quarterly Report (Q3)

January 31

Year-End Report (YE)

July 31 Mid-Year

Report (Non-election

Year Only) (MY)

Termination Report (TER)

(b) Monthly

Feb 20 (M2)

May 20 (M5)

Aug 20 (M8)

Nov 20 (M11)

Report

(Non-Election

Due On:

Year Only)

Mar 20 (M3)

Jun 20 (M6)

Sep 20 (M9)

Dec 20 (M12)

(Non-Election

Year Only)

Apr 20 (M4)

Jul 20 (M7)

Oct 20 (M10)

Jan 31 (YE)

(c)

12-Day

Primary (12P)

General (12G)

Runoff (12R)

PRE-Election

Report for the:

Convention (12C)

Special (12S)

in the

(d)

Election on

State of

30-Day

POST-Election

General (30G)

Runoff (30R)

Special (30S)

Report for the:

in the

Election on

State of

5.Covering Period

M M

D / Y Y Y Y

through

M M / D D / Y

I certify that I have examined this Report and to the best of my knowledge and belief it is true, correct and complete. Type or Print Name of Treasurer

Signature of Treasurer

Date

M M / D D / Y Y Y Y

NOTE: Submission of false, erroneous, or incomplete information may subject the person signing this Report to the penalties of 52 U.S.C. § 30109.

Office

Use

Only

FEC FORM 3X

Rev. 05/2016

Report Covering the Period:

From:

M M / D

/ Y Y Y

To:

M M / D D /

Y Y Y Y

COLUMN A	COLUMN B
This Period	Calendar Year-to-Date

6. (a) Cash on Hand
6. (a) Cash on Hand	Y	Y	Y	Y
January 1,

	(b) Cash on Hand at
		Beginning of Reporting Period
	(c)	Total Receipts (from Line 19)
	(d)	Subtotal (add Lines 6(b) and
		6(c) for Column A and Lines
		6(a) and 6(c) for Column B)

7.	Total Disbursements (from Line 31)

8.	Cash on Hand at Close of
	Reporting Period

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

▲,

▲.

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

	(subtract Line 7 from Line 6(d))

9.	Debts and Obligations Owed TO
	the Committee (Itemize all on
	Schedule C and/or Schedule D)

10.	Debts and Obligations Owed BY
	the Committee (Itemize all on
	Schedule C and/or Schedule D)

▲,	▲,	▲.	▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

This committee has qualified as a multicandidate committee. (see FEC FORM 1M)

For further information contact:

Federal Election Commission

1050 First Street, N.E.

Washington, DC 20463

Toll Free 800-424-9530

Local 202-694-1100

Report Covering the Period:

From:

M / D

Y Y Y Y

To:

M M / D D /

Y Y Y Y

I. Receipts

11. Contributions (other than loans) From:

(a) Individuals/Persons Other

Than Political Committees

COLUMN A	COLUMN B
Total This Period	Calendar Year-to-Date

		(i)	Itemized (use Schedule A)	............
		(ii)	Unitemized
		(iii) TOTAL (add
			Lines 11(a)(i) and (ii)	▼
	(b)	Political Party Committees
	(c)	Other Political Committees
		(such as PACs)
	(d)	Total Contributions (add Lines
		11(a)(iii), (b), and (c)) (Carry
12.		Totals to Line 33, page 5)		▼
	Transfers From Affiliated/Other
	Party Committees
13.	All Loans Received
14.	Loan Repayments Received
15.	Offsets To Operating Expenditures
	(Refunds, Rebates, etc.)
	(Carry Totals to Line 37, page 5)
16.	Refunds of Contributions Made
	to Federal Candidates and Other
	Political Committees
17.	Other Federal Receipts
	(Dividends, Interest, etc.)
18.	Transfers from Non-Federal and Levin Funds
	(a) Non-Federal Account

(from Schedule H3) .............................

(b)Levin Funds (from Schedule H5) .........

(c)Total Transfers (add 18(a) and 18(b)) ..

19.Total Receipts (add Lines 11(d),

12, 13, 14, 15, 16, 17, and 18(c)) .........▼

20.Total Federal Receipts

(subtract Line 18(c) from Line 19) .........▼

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

▲,

▲.

▲, ▲, ▲.

,	,	.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

▲,

▲.

▲, ▲, ▲.

DETAILED SUMMARY PAGE

FEC Form 3X (Rev. 05/2016 )

of Disbursements

Page 4

II. Disbursements

COLUMN A

COLUMN B

Total This Period

Calendar Year-to-Date

21.

Operating Expenditures:

(a) Allocated Federal/Non-Federal

Activity (from Schedule H4)

▲,

▲.

▲,

▲.

(i)

Federal Share

(ii)

Non-Federal Share

▲

(b)

Other Federal Operating

.......................................Expenditures

▲

(c)

Total Operating Expenditures

.............(add 21(a)(i), (a)(ii), and (b))

▼

▲

22.

Transfers to Affiliated/Other Party

.................................................Committees

▲,

▲.

▲,

▲.

23.

Contributions to

Federal Candidates/Committees

and Other Political Committees

▲

24.

Independent Expenditures

.......................................(use Schedule E)

▲,

▲.

▲,

▲.

25.

Coordinated Party Expenditures

(52 U.S.C. § 30116(d))

(use Schedule F)

▲,

▲.

▲,

▲.

26.

Loan Repayments Made

▲,

▲.

▲,

▲.

27.

Loans Made

▲,

▲.

▲,

▲.

28.

Refunds of Contributions To:

(a)

Individuals/Persons Other

Than Political Committees

▲,

▲.

▲,

▲.

(b)

Political Party Committees

▲,

▲.

▲,

▲.

(c)

Other Political Committees

...................................(such as PACs)

▲,

▲.

(d)

Total Contribution Refunds

...........(add Lines 28(a), (b), and (c))

▼

▲,

▲.

▲,

▲.

29.

Other Disbursements (Including

...................................Non-Federal Donations)

▲,

▲.

▲,

▲.

30. Federal Election Activity (52 U.S.C. § 30101(20))

(a)

Allocated Federal Election Activity

(from Schedule H6)

................................(i) Federal Share

▲,

▲.

▲,

▲.

(ii) "Levin" Share

▲,

▲.

▲,

▲.

(b) Federal Election Activity Paid

..............Entirely With Federal Funds

▲,

▲.

▲,

▲.

(c)

Total Federal Election Activity (add

.....Lines 30(a)(i), 30(a)(ii) and 30(b))

▼

▲,

▲.

▲,

▲.

31. Total Disbursements (add Lines 21(c), 22,

..23, 24, 25, 26, 27, 28(d), 29 and 30(c))

▲,

▲.

▲,

▲.

32.Total Federal Disbursements

(subtract Line 21(a)(ii) and Line 30(a)(ii) from Line 31)..............................................

▼

▲,

▲.

▲,

▲.

FEC Form 3X (Rev. 05/2016 )

III. Net Contributions/

Operating Expenditures

33. Total Contributions (other than loans)

DETAILED SUMMARY PAGE
	of Disbursements
	of Disbursements	Page 5
		Page 5
	COLUMN A	COLUMN B
	Total This Period	Calendar Year-to-Date

	(from Line 11(d), page 3)
34.	Total Contribution Refunds
	(from Line 28(d))
35.	Net Contributions (other than loans)
	(subtract Line 34 from Line 33)
36.	Total Federal Operating Expenditures
	(add Line 21(a)(i) and Line 21(b))	▼
	(add Line 21(a)(i) and Line 21(b))
37.	Offsets to Operating Expenditures
	(from Line 15, page 3)
38.	Net Operating Expenditures
	(subtract Line 37 from Line 36)	▼
	(subtract Line 37 from Line 36)

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

SCHEDULE A (FEC Form 3X)

ITEMIZED RECEIPTS

Use separate schedule(s) for each category of the Detailed Summary Page

FOR LINE NUMBER:			PAGE		OF
(check only one)
(check only one)			11c
	11a	11b	11c	12
	13	14	15	16		17

Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.

NAME OF COMMITTEE (In Full)

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Date of Receipt

Mailing Address

City

State

Zip Code

Amount of Each Receipt this Period

FEC ID number of contributing

▲,

▲.

federal political committee.

Memo Item

Name of Employer (for Individual)

Occupation (for Individual)

Receipt For:

Aggregate Year-to-Date

▼

Primary

General

Other (specify)

▼

▲,

▲.

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Date of Receipt

Mailing Address

City

State

Zip Code

Amount of Each Receipt this Period

FEC ID number of contributing

▲,

▲.

federal political committee.

Memo Item

Name of Employer (for Individual)

Occupation (for Individual)

Receipt For:

Aggregate Year-to-Date

▼

Primary

General

Other (specify)

▼

▲,

▲.

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Date of Receipt

Mailing Address

City

State

Zip Code

Amount of Each Receipt this Period

FEC ID number of contributing

federal political committee.

Memo Item

Name of Employer (for Individual)

Occupation (for Individual)

Receipt For:

Aggregate Year-to-Date

▼

Primary

General

Other (specify)

▲,

▲.

SUBTOTAL of Receipts This Page (optional)	▼

TOTAL This Period (last page this line number only)	▼

, , .

▲, ▲, ▲.

FEC Schedule A (Form 3X) Rev. 05/2016

SCHEDULE B (FEC Form 3X)

ITEMIZED DISBURSEMENTS

Use separate schedule(s) for each category of the Detailed Summary Page

FOR LINE NUMBER: (check only one)

21b		22

28a		28b

28c

PAGE OF

2627

2930b

NAME OF COMMITTEE (In Full)

Full Name (Last, First, Middle Initial)

Mailing Address

City

State

Zip Code

Purpose of Disbursement

Candidate Name

Category/

Type

Office Sought:

House

Disbursement For:

Senate

Primary

General

President

Other (specify)

▼

State:

District:

Full Name (Last, First, Middle Initial)

Mailing Address

City

State

Zip Code

Purpose of Disbursement

Candidate Name

Category/

Type

Office Sought:

House

Disbursement For:

Senate

Primary

General

State:

President

Other (specify)

District:

Full Name (Last, First, Middle Initial)

Mailing Address

City

State

Zip Code

Purpose of Disbursement

Candidate Name

Category/

Type

Office Sought:

House

Disbursement For:

Senate

Primary

General

President

Other (specify)

▼

State:

District:

SUBTOTAL of Disbursements This Page (optional)

▼

TOTAL This Period (last page this line number only)

▼

Date of Disbursement

M M / D D / Y Y Y Y

FEC Identification Number

Amount of Each Disbursement this Period

▲,

▲.

Memo Item

Date of Disbursement

M M / D D / Y Y Y Y

FEC Identification Number

Amount of Each Disbursement this Period

▲,

▲.

Memo Item

Date of Disbursement

M M / D D / Y Y Y Y

FEC Identification Number

Amount of Each Disbursement this Period

▲,

▲.

Memo Item

▲,

▲.

, , .

FEC Schedule B (Form 3X) Rev. 05/2016

SCHEDULE C		(FEC Form 3X)
LOANS			Use separate schedule(s)		PAGE	OF
LOANS			for each category of the
			for each category of the
			Detailed Summary Page		FOR LINE 13 OF FORM 3X

NAME OF COMMITTEE (In Full)

	LOAN SOURCE	Full Name (Last, First, Middle Initial)	Memo Item	Election:
					Primary
					General
	Mailing Address				Other (specify) ▼

City

State

ZIP Code

Original Amount of Loan

Cumulative Payment To Date

Balance Outstanding at Close of This Period

▲,

▲.

▲,

▲.

▲,

▲.

TERMS

Date Incurred

M M / D D / Y Y Y Y

Date Due

M M / D D / Y Y Y Y

Interest Rate

▲.

	Secured:
% (apr)	Yes	No

List All Endorsers or Guarantors (if any) to Loan Source

Full Name (Last, First, Middle Initial)

Name of Employer

Mailing Address

Occupation

City

State

ZIP Code

Amount

Guaranteed

▲,

▲.

Outstanding:

Full Name (Last, First, Middle Initial)

Name of Employer

Mailing Address

Occupation

City

State

ZIP Code

Amount

Guaranteed

▲,

▲.

Outstanding:

Full Name (Last, First, Middle Initial)

Name of Employer

Mailing Address

Occupation

City

State

ZIP Code

Amount

Guaranteed

▲,

▲.

Outstanding:

Full Name (Last, First, Middle Initial)

Name of Employer

Mailing Address

Occupation

City

State

ZIP Code

Amount

Guaranteed

▲,

▲.

Outstanding:

SUBTOTALS This Period This Page (optional)	▼

TOTALS This Period (last page in this line only)	▼

▲,

▲.

, , .

Carry outstanding balance only to LINE 3, Schedule D, for this line. If no Schedule D, carry forward to appropriate line of Summary.

FEC Schedule C (Form 3X) Rev. 05/2016

SCHEDULE C–1 (FEC Form 3X)

LOANS AND LINES OF CREDIT FROM LENDING INSTITUTIONS

Federal Election Commission, Washington, D.C. 20463

Supplementary for

Information found on

Page

of Schedule C

NAME OF COMMITTEE (In Full)

FEC IDENTIFICATION NUMBER

LENDING INSTITUTION (LENDER)

Full Name

Mailing Address

City	State Zip Code

Amount of Loan

Interest Rate (APR)

▲,

▲.

Date Incurred or Established

Date Due

Has loan been restructured?

Yes

If yes, date originally incurred

If line of credit,

Total

Outstanding

▲,

▲.

▲,

▲.

Amount of this Draw:

Balance:

C. Are other parties secondarily liable for the debt incurred?

Yes

(Endorsers and guarantors must be reported on Schedule C.)

Are any of the following pledged as collateral for the loan: real estate, personal

What is the value of this collateral?

property, goods, negotiable instruments, certificates of deposit, chattel papers,

stocks, accounts receivable, cash on deposit, or other similar traditional collateral?

▲,

▲.

Yes

If yes, specify:

Does the lender have a perfected security

interest in it?

Yes

Are any future contributions or future receipts of interest income, pledged as

What is the estimated value?

collateral for the loan?

Yes If yes, specify:

▲,

▲.

A depository account must be established pursuant to 11 CFR 100.82(e)(2) and 100.142(e)(2).

Date account established:

M M / D D / Y Y Y Y

Location of account:

Address:

City, State, Zip:

F.If neither of the types of collateral described above was pledged for this loan, or if the amount pledged does not equal or exceed the loan amount, state the basis upon which this loan was made and the basis on which it assures repayment.

G.COMMITTEE TREASURER Typed Name

Signature

DATE

M M / D D /

Y Y Y Y

H.Attach a signed copy of the loan agreement.

I.TO BE SIGNED BY THE LENDING INSTITUTION:

I.To the best of this institution’s knowledge, the terms of the loan and other information regarding the extension of the loan are accurate as stated above.

II.The loan was made on terms and conditions (including interest rate) no more favorable at the time than those imposed for similar extensions of credit to other borrowers of comparable credit worthiness.

III.This institution is aware of the requirement that a loan must be made on a basis which assures repayment, and has complied with the requirements set forth at 11 CFR 100.82 and 100.142 in making this loan.

AUTHORIZED REPRESENTATIVE

Typed Name

Signature

Title

DATE

M M

/ D D / Y Y Y Y

FEC Schedule C-1 (Form 3X) Rev. 05/2016

SCHEDULE D

(FEC Form 3X)

(Use separate

PAGE

FOR LINE NUMBER:

DEBTS AND OBLIGATIONS

schedule(s)

for each

(check only one)

Excluding Loans

numbered line)

NAME OF COMMITTEE (In Full)

A. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Nature of Debt (Purpose):

Mailing Address

City

State

Zip Code

Outstanding Balance Beginning This Period

▲,

▲.

Amount Incurred This Period

Payment This Period

Outstanding Balance at Close of This Period

▲,

▲.

▲,

▲.

▲,

▲.

B. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Nature of Debt (Purpose):

Mailing Address

City

State

Zip Code

Outstanding Balance Beginning This Period

▲,

▲.

Outstanding Balance at Close of This Period

Amount Incurred This Period

Payment This Period

▲,

▲.

▲,

▲.

▲,

▲.

C. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Nature of Debt (Purpose):

Mailing Address

City

State

Zip Code

Outstanding Balance Beginning This Period

▲,

▲.

Amount Incurred This Period

Payment This Period

▲,

▲.

▲,

▲.

SUBTOTALS This Period This Page (optional)

▼

TOTALS This Period (last page this line number only)

▼

TOTAL OUTSTANDING LOANS from Schedule C (last page only)

▼

ADD 2) and 3) and carry forward to appropriate line of Summary Page (last page only) ▼

Outstanding Balance at Close of This Period

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

FEC Schedule D (Form 3X) Rev. 05/2016

SCHEDULE E (FEC Form 3X)

ITEMIZED INDEPENDENT EXPENDITURES

PAGE

FOR LINE 24 OF FORM 3X

NAME OF COMMITTEE (In Full)

FEC IDENTIFICATION NUMBER ▼

Check if

24-hour report

48-hour report

New report

Amends report filed on

Full Name of Payee

Mailing Address

City

Purpose of Expenditure

Memo Item

State

Zip Code

Category/

Type

Date of Public Distribution/Dissemination

M M / D D / Y Y Y Y

Amount

▲, ▲, ▲.

Date of Disbursement or Obligation

M M / D D / Y Y Y Y

Name of Federal Candidate:

Calendar Year-To-Date

Per Election for Office Sought

Support

Office Sought:

House

District:

Oppose

President

Senate

State:

Disbursement For:

Primary

General

▲,

▲.

Other (specify) ▼

Full Name of Payee

Mailing Address

City

Purpose of Expenditure

Memo Item

State	Zip Code
	Category/
	Type

Date of Public Distribution/Dissemination

M M / D D / Y Y Y Y

Amount

▲, ▲, ▲.

Date of Disbursement or Obligation

M M / D D / Y Y Y Y

Name of Federal Candidate:

Calendar Year-To-Date

Per Election for Office Sought

Support

Office Sought:

House

District:

Oppose

President

Senate

State:

Disbursement For:

Primary

General

▲,

▲.

Other (specify) ▼

(a) SUBTOTAL of Itemized Independent Expenditures ..............................................................

(a) SUBTOTAL of Unitemized Independent Expenditures..........................................................

(a) TOTAL Independent Expenditures ........................................................................................

▼ ▼ ▼

▲, ▲, ▲.

Under penalty of perjury I certify that the independent expenditures reported herein were not made in cooperation, consultation, or concert with, or at the request or suggestion of, any candidate or authorized committee or agent of either, or (if the reporting entity is not a political party committee) any political party committee or its agent.

Signature

Date

M M / D D / Y Y Y Y

FEC Schedule E (Form 3X) Rev. 0/2016

SCHEDULE F

(FEC Form 3X)

ITEMIZED COORDINATED PARTY EXPENDITURES MADE BY

POLITICAL PARTY COMMITTEES OR DESIGNATED AGENT(S)

ON BEHALF OF CANDIDATES FOR FEDERAL OFFICE

PAGE

(To be used only by Political Committees in the General Election)

FOR LINE 25 OF FORM 3X

NAME OF COMMITTEE (In Full)

Has your committee been designated to make

Full Name of Subordinate Committee

coordinated expenditures by a political party committee?

YES

If YES, name the designating committee:

Mailing Address

City

State

ZIP Code

Full Name (Last, First, Middle Initial) of Each Payee

Memo Item

Purpose of Expenditure

Category/

Mailing Address

Type

Date

City

State

Zip Code

Name of Federal Candidate Supported

Office Sought:

House

State:

Amount

Senate

District:

Presidential

▲,

▲.

Aggregate General Election

▲,

▲.

Expenditure for this Candidate ▼

Full Name (Last, First, Middle Initial) of Each Payee

Memo Item

Purpose of Expenditure

Category/

Mailing Address

Type

Date

City

State

Zip Code

Name of Federal Candidate Supported

Office Sought:

House

State:

Amount

Senate

District:

Presidential

▲,

▲.

Aggregate General Election

▲,

▲.

Expenditure for this Candidate ▼

Full Name (Last, First, Middle Initial) of Each Payee

Memo Item

Purpose of Expenditure

Category/

Mailing Address

Type

Date

City

State

Zip Code

Name of Federal Candidate Supported

Office Sought:

House

State:

Amount

Senate

District:

Presidential

▲,

▲.

Aggregate General Election

▲,

▲.

Expenditure for this Candidate ▼

SUBTOTAL of Expenditures This Page (optional)	▼

TOTAL This Period (last page this line number only)	▼

▲,

▲.

▲, ▲, ▲.

FEC Schedule F (Form 3X) Rev. 05/2016

SCHEDULE H1 (FEC Form 3X)

METHOD OF ALLOCATION FOR:

●ALLOCATED FEDERAL AND NONFEDERAL ADMINISTRATIVE, GENERIC VOTER DRIVE AND EXEMPT ACTIVITY COSTS

●ALLOCATED FEDERAL AND LEVIN FUNDS FEDERAL ELECTION ACTIVITY EXPENSES (State, District and Local Party Committees Only)

●ALLOCATED PUBLIC COMMUNICATIONS THAT REFER TO ANY POLITICAL PARTY (BUT NOT A CANDIDATE) (Separate Segregated Funds And Nonconnected Committees Only)

NAME OF COMMITTEE (In Full)

USE ONLY ONE SECTION, A or B

A. State and Local Party Committees

Fixed Percentage (select one)

Presidential-Only Election Year (28% Federal)

Presidential and Senate Election Year (36% Federal)

Senate-Only Election Year (21% Federal)

Non-Presidential and Non-Senate Election Year (15% Federal)

B. Separate Segregated Funds and Nonconnected Committees

Indicate ratio below

Federal.......................................................................

Nonfederal .................................................................

This ratio applies to (check all that apply):

▲.

Administrative

Generic Voter Drive

Public Communications Referencing Party Only

FEC Schedule H1 (Form 3X) Rev.05/2016

SCHEDULE H2 (FEC Form 3X)

ALLOCATION RATIOS

NAME OF COMMITTEE (In Full)

PAGE OF

RATIOS FOR ALLOCABLE FUNDRAISING EVENTS AND DIRECT CANDIDATE SUPPORT

ACTIVITIES APPEARING ON THIS REPORT.

Methods of allocation:

I.FUNDRAISING activities are allocated using the “funds received method” where the federal proportion of expenses must equal the federal proportion of monies raised.

II.Shared DIRECT CANDIDATE SUPPORT activities are allocated according to benefit expected to be derived, where the federal proportion of disbursements is based on the benefit derived by federal candidates from the ac - tivity. For PACs Only: Direct candidate support includes public communications or voter drives that refer to both federal and nonfederal candidates, regardless of whether there is a reference to a political party. Such expenses are allocated using a time/space method.

ACTIVITY OR EVENT IDENTIFIER

FEDERAL %

NONFEDERAL %

ACTIVITY IS:

Fundraising

Direct Candidate Support

▲

CHECK IF THE RATIO IS:

New

Revised

Same as Previously Reported

ACTIVITY OR EVENT IDENTIFIER

FEDERAL %

NONFEDERAL %

ACTIVITY IS:

Fundraising

Direct Candidate Support

▲

CHECK IF THE RATIO IS:

New

Revised

Same as Previously Reported

ACTIVITY OR EVENT IDENTIFIER

FEDERAL %

NONFEDERAL %

ACTIVITY IS:

Fundraising

Direct Candidate Support

▲

CHECK IF THE RATIO IS:

New

Revised

Same as Previously Reported

ACTIVITY OR EVENT IDENTIFIER

FEDERAL %

NONFEDERAL %

ACTIVITY IS:

Fundraising

Direct Candidate Support

▲

CHECK IF THE RATIO IS:

New

Revised

Same as Previously Reported

ACTIVITY OR EVENT IDENTIFIER

FEDERAL %

NONFEDERAL %

ACTIVITY IS:

Fundraising

Direct Candidate Support

▲

CHECK IF THE RATIO IS:

New

Revised

Same as Previously Reported

ACTIVITY OR EVENT IDENTIFIER

FEDERAL %

NONFEDERAL %

ACTIVITY IS:

Fundraising

Direct Candidate Support

▲

CHECK IF THE RATIO IS:

New

Revised

Same as Previously Reported

FEC Schedule H2 (Form 3X) Rev. 05/2016

SCHEDULE H3 (FEC Form 3X)

TRANSFERS FROM NONFEDERAL ACCOUNTS FOR ALLOCATED FEDERAL / NONFEDERAL ACTIVITY

PAGE OF

FOR LINE 18a OF FORM 3X

NAME OF COMMITTEE (In Full)

NAME OF ACCOUNT

DATE OF RECEIPT

M M / D D

/ Y Y Y Y

TOTAL AMOUNT TRANSFERRED

▲, ▲, ▲.

BREAKDOWN OF TRANSFER RECEIVED

i)Total Administrative .............................................................................................................

ii)Generic Voter Drive .............................................................................................................

iii)Exempt Activities...................................................................................................................

iv)Direct Fundraising (List Activity or Event Identifier)

▲,

▲.

▲,

▲.

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

c)Total Amount Transferred For Direct Fundraising .............................................................

v)Direct Candidate Support (List Activity or Event Identifier)

▲

▲,

▲.

c) Total Amount Transferred For Direct Candidate Support

▲,

▲.

vi) Public Communications Referring Only to Party (Made by PAC)

▲,

▲.

TOTALS FOR BREAKDOWN OF TRANSFER RECEIVED

TOTAL This Period (Administrative) ..........................................................

TOTAL This Period (Generic Voter Drive) .......................................................

▲,

▲.

▲, ▲, ▲.

TOTAL This Period (Exempt Activities) ..................................................................

▲,

▲.

TOTAL This Period (Direct Fundraising) .......................................................................

▲,

▲.

TOTAL This Period (Direct Candidate Support) ..................................................................

TOTAL This Period (Public Communications Referring Only to Party) ......................................

▲,

▲.

▲, ▲, ▲.

TOTAL This Period (Total Amount Transferred)................................................................................

▲,

▲.

FEC Schedule H3 (Form 3X) Rev. 05/2016

SCHEDULE H4 (FEC Form 3X)

DISBURSEMENTS FOR ALLOCATED

PAGE

FEDERAL/NONFEDERAL ACTIVITY

FOR LINE 21a OF FORM 3X

NAME OF COMMITTEE (In Full)

A. Full Name (Last, First, Middle Initial)

Memo Item

Allocated Activity or Event:

Administrative

Fundraising

Exempt

Mailing Address

Voter Drive

Direct Candidate Support

Public Comm (ref to party only) by PAC

City

State

Zip Code

Allocated Activity or Event Year-To-Date

Purpose of Disbursement:

▲,

▲.

Activity or Event Identifier:

Category/

Type

Date

FEDERAL SHARE

NONFEDERAL SHARE

TOTAL AMOUNT

▲,

▲.

▲,

▲.

▲,

▲.

B. Full Name (Last, First, Middle Initial)

Memo Item

Allocated Activity or Event:

Administrative

Fundraising

Exempt

Mailing Address

Voter Drive

Direct Candidate Support

Public Comm (ref to party only) by PAC

City

State

Zip Code

Allocated Activity or Event Year-To-Date

Purpose of Disbursement:

▲,

▲.

Activity or Event Identifier:

Category/

Type

Date

FEDERAL SHARE

NONFEDERAL SHARE

TOTAL AMOUNT

▲,

▲.

▲,

▲.

▲,

▲.

C. Full Name (Last, First, Middle Initial)

Memo Item

Allocated Activity or Event:

Administrative

Fundraising

Exempt

Mailing Address

Voter Drive

Direct Candidate Support

Public Comm (ref to party only) by PAC

City

State

Zip Code

Allocated Activity or Event Year-To-Date

Purpose of Disbursement:

▲,

▲.

Activity or Event Identifier:

Category/

Type

Date

FEDERAL SHARE

NONFEDERAL SHARE

TOTAL AMOUNT

▲,

▲.

▲,

▲.

▲,

▲.

SUBTOTAL of Allocated Federal and NonFederal Activity This Page
FEDERAL SHARE	+	NONFEDERAL SHARE	=	TOTAL AMOUNT

▲,

▲.

▲,

▲.

▲,

▲.

TOTAL This Period (last page for each line only)(Federal share to 21(a)(i) and NonFederal share to 21(a)(ii))
FEDERAL SHARE	NONFEDERAL SHARE	TOTAL AMOUNT

▲,

▲.

▲,

▲.

▲,

▲.

FEC Schedule H4 (Form 3X) Rev. 05/2016

SCHEDULE H5 (FEC Form 3X)

TRANSFERS OF LEVIN FUNDS RECEIVED FOR ALLOCATED FEDERAL ELECTION ACTIVITY

(To be used by State, District and Local Party Committees Only)

PAGE OF

FOR LINE 18b OF FORM 3X

NAME OF COMMITTEE (In Full)

NAME OF ACCOUNT

DATE OF RECEIPT

M M / D D

/ Y Y

Y Y

TOTAL AMOUNT TRANSFERRED

▲, ▲, ▲.

BREAKDOWN OF THIS TRANSFER

i)Voter Registration

Total Amount Transferred for Voter Registration......

VOTER REGISTRATION

▲, ▲, ▲.

ii) Voter ID

Total Amount Transferred for Voter ID ...............................

VOTER ID

▲, ▲, ▲.

iii) GOTV

Total Amount Transferred for GOTV .................................................

GOTV

, , .

iv) Generic Campaign Activity

Total Amount Transferred for Generic Campaign Activity ..............................

GENERIC CAMPAIGN ACTIVITY

▲, ▲, ▲.

NAME OF ACCOUNT

DATE OF RECEIPT

M M / D D

/ Y Y Y Y

TOTAL AMOUNT TRANSFERRED

▲, ▲, ▲.

BREAKDOWN OF THIS TRANSFER

i)Voter Registration

Total Amount Transferred for Voter Registration......

VOTER REGISTRATION

, , .

VOTER ID

ii) Voter ID

Total Amount Transferred for Voter ID ...............................

▲,

▲.

iii) GOTV

Total Amount Transferred for GOTV .................................................

GOTV

▲, ▲, ▲.

iv) Generic Campaign Activity

Total Amount Transferred for Generic Campaign Activity ..............................

GENERIC CAMPAIGN ACTIVITY

▲, ▲, ▲.

TOTALS FOR BREAKDOWN OF TRANSFER RECEIVED (Last Page Only)

TOTAL This Period (Voter Registration)..............................

▲,

▲.

TOTAL This Period (Voter ID) .......................................................

▲,

▲.

TOTAL This Period (GOTV).............................................................................

▲,

▲.

TOTAL This Period (Generic Campaign Activity).......................................................

▲,

▲.

TOTAL This Period (Total Amount of Transfers Received) ....................................................

▲,

▲.

FEC Schedule H5 (Form 3X) Rev. 05/2016

SCHEDULE H6 (FEC Form 3X)
DISBURSEMENTS OF FEDERAL AND LEVIN FUNDS
DISBURSEMENTS OF FEDERAL AND LEVIN FUNDS	PAGE	OF
FOR ALLOCATED FEDERAL ELECTION ACTIVITY	PAGE	OF
FOR ALLOCATED FEDERAL ELECTION ACTIVITY
(To be used by State, District and Local Party Committees Only)	FOR LINE 30a OF FORM 3X

NAME OF COMMITTEE (In Full)

A. Full Name (Last, First, Middle Initial) / Full Organization Name			Memo Item

Mailing Address

City	State	Zip Code

Purpose of Disbursement			Category/
				Type

Type of Allocated Activity or Event:

Voter Registration

GOTV

Voter ID

Generic Campaign

Allocated Activity or Event Year-To-Date

▲,

▲.

Date

FEDERAL SHARE

▲,

▲.

LEVIN SHARE

▲,

▲.

TOTAL AMOUNT

▲, ▲, ▲.

B. Full Name (Last, First, Middle Initial) / Full Organization Name			Memo Item

Mailing Address

City	State	Zip Code

Purpose of Disbursement			Category/
				Type

Type of Allocated Activity or Event:

Voter Registration

GOTV

Voter ID

Generic Campaign

Allocated Activity or Event Year-To-Date

▲,

▲.

Date

FEDERAL SHARE

▲,

▲.

LEVIN SHARE

, , .

TOTAL AMOUNT

▲, ▲, ▲.

C. Full Name (Last, First, Middle Initial) / Full Organization Name			Memo Item

Mailing Address

City	State	Zip Code

Purpose of Disbursement			Category/
				Type

Type of Allocated Activity or Event:

Voter Registration

GOTV

Voter ID

Generic Campaign

Allocated Activity or Event Year-To-Date

▲,

▲.

Date

FEDERAL SHARE

, , .

LEVIN SHARE

▲,

▲.

TOTAL AMOUNT

▲, ▲, ▲.

SUBTOTAL of Shared Federal and Levin Activity This Page

FEDERAL SHARE

LEVIN SHARE

▲,

▲.

▲,

▲.

TOTAL This Period (last page for each line only)(Federal share to 30(a)(i) and Levin share to 30(a)(ii))

FEDERAL SHARE

▲,

▲.

LEVIN SHARE

TOTAL This Period for the Levin Share

▲,

▲.

TOTAL AMOUNT

▲,

▲.

TOTAL AMOUNT

▲, ▲, ▲.

FEC Schedule H6 (Form 3X) Rev. 05/2016

SCHEDULE L (FEC Form 3X)

AGGREGATION PAGE: LEVIN FUNDS

NAME OF COMMITTEE (In Full)

NAME OF ACCOUNT

1.RECEIPTS FROM PERSONS

COLUMN A	COLUMN B
TOTAL THIS PERIOD	YEAR-TO-DATE

(a) Itemized .....................................

(Use Schedule L–A)

(b)Unitemized ..................................

(c)Total .............................................

2.OTHER RECEIPTS................................

3.TOTAL RECEIPTS .................................

(Add Lines 1c and 2)

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

4.TRANSFERS TO FEDERAL OR

ALLOCATION ACCOUNT

(Use Schedule L–B)

(a)Voter Registration .......................

(b)Voter ID.......................................

(c)GOTV ..........................................

(d)Generic Campaign......................

(e)Total.............................................

5.OTHER DISBURSEMENTS...................

6.TOTAL DISBURSEMENTS ....................

(Add Lines 4e and 5)

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

7. BEGINNING CASH ON HAND..............

(for Column B, use cash as of January 1st)

8. RECEIPTS ..............................................

(from Line 3)

9. SUBTOTAL ............................................

(Add Lines 7 and 8)

10. DISBURSEMENTS .................................

(From Line 6)

11. ENDING CASH ON HAND ..............................

(Subtract Line 10 From Line 9) ....................................

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.
,	,	.

FEC Schedule L (Form 3X) Rev. 05/2016

SCHEDULE L–A (FEC Form 3X)	Use separate schedule(s)		PAGE	OF
	Use separate schedule(s)	FOR LINE NUMBER:
ITEMIZED RECEIPTS OF LEVIN FUNDS	for each category of the	FOR LINE NUMBER:
	Aggregation Page	(check only one)	1a	2
			1a	2

NAME OF COMMITTEE (In Full)

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name Memo Item

Mailing Address

City

State

Zip Code

Name of Employer (for Individual)

Occupation (for Individual)

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name Memo Item

Mailing Address

City

State

Zip Code

Name of Employer (for Individual)

Occupation (for Individual)

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name Memo Item

Mailing Address

City

State

Zip Code

Name of Employer (for Individual)

Occupation (for Individual)

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name Memo Item

	Mailing Address

	City	State	Zip Code

	Name of Employer (for Individual)

	Occupation (for Individual)
SUBTOTAL of Receipts This Page (optional)			▼
SUBTOTAL of Receipts This Page (optional)			▼

TOTAL This Period (last page this line number only)			▼

Date of Receipt

M M / D D / Y Y Y Y

Amount of Each Receipt this Period

▲,

▲.

Aggregate Year-to-Date

▲,

▲.

Date of Receipt

Amount of Each Receipt this Period

▲,

▲.

Aggregate Year-to-Date

▲,

▲.

Date of Receipt

Amount of Each Receipt this Period

▲,

▲.

Aggregate Year-to-Date

▲,

▲.

Date of Receipt

Amount of Each Receipt this Period

▲,

▲.

Aggregate Year-to-Date

▲,

▲.

▲,

▲.

▲,

▲.

FEC Schedule L–A (Form 3X) Rev. 05/2016

SCHEDULE L–B (FEC Form 3X)

ITEMIZED DISBURSEMENTS OF LEVIN FUNDS

Use separate schedule(s) for each category of the Aggregation Page

FOR LINE NUMBER: (check only one)


	PAGE		OF

4a		4c	5
4b		4d

	NAME OF COMMITTEE (In Full)
	Full Name (Last, First, Middle Initial) / Full Organization Name
			Memo Item
A.

	Mailing Address
	City	State	Zip Code
	City	State	Zip Code

	Purpose of Disbursement
	Full Name (Last, First, Middle Initial) / Full Organization Name		Memo Item
B.

	Mailing Address
	City	State	Zip Code
	City	State	Zip Code

	Purpose of Disbursement
	Full Name (Last, First, Middle Initial) / Full Organization Name		Memo Item
C.

	Mailing Address
	City	State	Zip Code
	City	State	Zip Code

	Purpose of Disbursement
	Full Name (Last, First, Middle Initial) / Full Organization Name		Memo Item
D.

	Mailing Address
	City	State	Zip Code
	City	State	Zip Code

	Purpose of Disbursement
	Full Name (Last, First, Middle Initial) / Full Organization Name		Memo Item
E.

	Mailing Address
	City	State	Zip Code
	City	State	Zip Code

	Purpose of Disbursement
SUBTOTAL of Disbursements This Page (optional)
SUBTOTAL of Disbursements This Page (optional)			▼

TOTAL This Period (last page this line number only)			▼

Date of Disbursement

M M / D D / Y Y Y Y

Amount of Each Disbursement this Period

▲,

▲.

Date of Disbursement

M M / D D / Y Y Y Y

Amount of Each Disbursement this Period

▲,

▲.

Date of Disbursement

M M / D D / Y Y Y Y

Amount of Each Disbursement this Period

▲,

▲.

Date of Disbursement

M M / D D / Y Y Y Y

Amount of Each Disbursement this Period

▲,

▲.

Date of Disbursement

M M / D D / Y Y Y Y

Amount of Each Disbursement this Period

▲,	▲,	▲.
▲,	▲,	▲.
▲,	▲,	▲.

FEC Schedule L–B (Form 3X) Rev. 05/2016

Question	Answer
Form Name	Fec 3X Form
Form Length	21 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min 15 sec
Other names	name form 3x online, fec filing schedule, fec form 3x fillable form, fec form 3x

SUMMARY PAGE

FEC Form 3X (Rev. 05/2016 )

OF RECEIPTS AND DISBURSEMENTS

OF RECEIPTS AND DISBURSEMENTS

Write or Type Committee Name