Form D 1 Statement Organization Illinois – Fill Out and Use This PDF

SEE PAMPHLET “A GUIDE TO CAMPAIGN DISCLOSURE” FOR GUIDANCE.

1.	DATE COMMITTEE CREATED:	2.	AMOUNT OF FUNDS AVAILABLE AS OF
			CREATION DATE :$__________________
	NEW COMMITTEE (MUST BE FILED WITHIN 10 DAYS OF CREATION OR WITHIN 2 DAYS IF CREATED WITHIN 30 DAYS
3.	BEFORE AN ELECTION.)
	AMENDMENT (MUST BE FILED WITHIN 10 DAYS OF ANY CHANGES. ENTER ONLY THOSE CHANGES FROM LAST D-1
	ON FILE.)
	REACTIVATING
4.	POLITICAL COMMITTEE’S DESIGNATION: ALL COMMITTEES CHOOSE ONLY ONE:
	CANDIDATE POLITICAL COMMITTEE*
	*For purposes of contribution limits and reporting requirements a Candidate Political Committee supporting a candidate for
	multiple offices elected at different elections must designate an election cycle by listing the appropriate office. This office is:
	__________________________________.
	POLITICAL ACTION COMMITTEE
	POLITICAL PARTY COMMITTEE
	BALLOT INITIATIVE COMMITTEE
	INDEPENDENT-EXPENDITURE-ONLY PAC**

**May not make direct contributions or coordinated expenditures.

5.POLITICAL COMMITTEE’S AREA OF ACTIVITY, SCOPE, AND PARTY AFFILIATION.

A. THIS COMMITTEE WILL PRIMARILY OPERATE IN THE FOLLOWING COUNTY(IES) OR DISTRICT(S):

(not applicable if operating statewide or supporting/opposing statewide candidates or ballot initiatives)

_______________________________________________________________________________________________

B.POLITICAL PARTY AFFILIATION:______________________________________

C.NAME AND ADDRESS OF EACH SPONSORING ENTITY:

6.PURPOSE OF THE POLITICAL COMMITTEE.

7.CANDIDATE(S) THE COMMITTEE IS SUPPORTING OR OPPOSING. (IF AMENDING, LIST ALL AS OF TODAY’S DATE.)

IF MORE SPACE FOR INFORMATION IS REQUIRED, PLEASE ATTACH ADDITIONAL SHEETS.

THIS FORM MAY BE REPRODUCED

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Revised 7/9/12

POSITION

NAME

MAILING ADDRESS, DAYTIME PHONE NUMBER, AND E-MAIL ADDRESS

CHAIRMAN

TREASURER

10.	LIST OF ALL FINANCIAL INSTITUTIONS AND OTHER REPOSITORIES OF THE COMMITTEE FUNDS.
	(IF AMENDING, LIST ALL AS OF TODAY’S DATE.)
	NAME		MAILING ADDRESS AND PHONE NUMBER

11. DISPOSITION OF RESIDUAL FUNDS IN THE EVENT OF DISSOLUTION OR TERMINATION OF THE COMMITTEE:

RETURN TO CONTRIBUTORS IN AMOUNTS NOT TO EXCEED THEIR INDIVIDUAL CONTRIBUTIONS. TRANSFER TO ANOTHER POLITICAL COMMITTEE:

TRANSFER TO A CHARITABLE ORGANIZATION:

IF MORE SPACE FOR INFORMATION IS REQUIRED, PLEASE ATTACH ADDITIONAL SHEETS.

VERIFICATION- BALLOT INITIATIVE COMMITTEES ONLY

I DECLARE THAT THIS BALLOT INITIATIVE COMMITTEE IS FORMED FOR THE PURPOSE OF SUPPORTING OR OPPOSING A QUESTION OF PUBLIC POLICY, ALL CONTRIBUTIONS AND EXPENDITURES OF THE COMMITTEE WILL BE USED FOR THE PURPOSE DESCRIBED IN THIS STATEMENT OF ORGANIZATION, THE COMMITTEE MAY ACCEPT UNLIMITED CONTRIBUTIONS FROM ANY SOURCE, PROVIDED THAT THIS BALLOT INITIATIVE COMMITTEE DOES NOT MAKE CONTRIBUTIONS OR EXPENDITURES IN SUPPORT OF OR OPPOSITION TO A CANDIDATE OR CANDIDATES FOR NOMINATION FOR ELECTION, ELECTION, OR RETENTION, AND FAILURE TO ABIDE BY THESE REQUIREMENTS SHALL DEEM THIS COMMITTEE IN VIOLATION OF THIS ARTICLE. (10 ILCS 5/9)

PRINTED AND WRITTEN SIGNATURE OF COMMITTEE CHAIRPERSON

DATE

VERIFICATION: INDEPENDENT EXPENDITURE COMMITTEES ONLY

I DECLARE THAT ( i) THIS INDEPENDENT EXPENDITURE COMMITTEE IS FORMED FOR THE EXCLUSIVE PURPOSE OF MAKING INDEPENDENT EXPEN DITURES, ( ii) ALL CONTRIBUTIONS AND EXPENDITURES O F THE COMMITTEE WILL BE USED FOR T HE PU RPOSE D ESCRIBED I N T HE ST ATEMENT O F O RGANIZATION, (iii) T HE C OMMITTEE MAY ACCEPT UNL IMITED CO NTRIBUTIONS FROM ANY SOURCE, PROVIDED THAT THE INDEPENDENT EXPENDITURE COMMITTEE DOES NOT MAKE CONTRIBUTIONS TO ANY CANDIDATE POLITICAL COMMITTEE, POLITICAL PARTY COMMITTEE, OR POLITICAL ACTION COMMITTEE, AND (iv) FAILURE TO ABIDE BY THESE REQUIREMENTS SHALL DEEM THE COMMITTEE IN VIOLATION OF THIS ARTICLE.

PRINTED AND WRITTEN SIGNATURE OF COMMITTEE CHAIRPERSON

DATE

VERIFICATION: ALL POLITICAL COMMITTEES

I DECLARE THAT THIS STATEMENT OF ORGANIZATION (INCLUDING ANY ACCOMPANYING SCHEDULES AND STATEMENTS) HAS BEEN EXAMINED BY ME AND, TO THE BEST OF MY KNOWLEDGE AND BELIEF, IS A TRUE, CORRECT, AND COMPLETE STATEMENT OF ORGANIZATION AS REQUIRED BY ARTICLE 9 OF THE ELECTION CODE. I UNDERSTAND THAT WILLFULLY FILING A FALSE OR INCOMPLETE STATEMENT IS SUBJECT TO A CIVIL PENALTY OF AT LEAST $1001 AND UP TO $5000.

PRINTED AND WRITTEN SIGNATURE OF TREASURER OR CANDIDATE

DATE

THE ILLINOIS STATE BOARD OF ELECTIONS REQUIRES THE DISCLOSURE OF INFORMATION THAT IS NECESSARY IF YOU QUALIFY AS A POLITICAL COMMITTEE AS OUTLINED UNDER PUBLIC ACT 78-1183. WILLFUL FAILURE TO FILE OR WILLFUL FILING OF FALSE OR INCOMPLETE INFORMATION REQUIRED BY THIS ARTICLE SHALL CONSTITUTE A BUSINESS OFFENSE SUBJECT TO A FINE OF UP TO $5000. THIS FORM IS IN COMPLIANCE WITH THE FORMS MANAGEMENT PROGRAM ACT.

ALL POLITICAL COMMITTEES RETURN TO:

	STATE BOARD OF ELECTIONS	STATE BOARD OF ELECTIONS
		JAMES R. THOMPSON CENTER
	2329 S MACARTHUR BLVD
		100 W RANDOLPH ST, STE 14-100
	SPRINGFIELD, IL 62704-4503
		CHICAGO, IL. 60601-3232
	fax: 217-557-5630
		fax: 312-814-6485
	e-mail: D1@ELECTIONS.IL.GOV(D-1s ONLY)
		e-mail: D1@ELECTIONS.IL.GOV(D-1s ONLY)

www.elections.il.gov

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