Pa Campaign Form PDF Details

In the intricate world of political campaign finance, the Commonwealth of Pennsylvania has established a structured approach to maintain transparency and accountability among candidates, committees, and lobbyists through the Campaign Finance Report. The hallmark of this report is its comprehensive requirement for filers to elucidate all financial activities within a specified reporting period, ensuring each contribution and expenditure is meticulously documented. Whether the report is filed by a candidate committee or a lobbyist, crucial information such as name, address, and the type of report is systematically recorded. This approach facilitates various reporting schedules aimed at capturing financial activities at critical junctures of the campaign cycle, such as pre-primary, pre-election, election, and post-election periods. Importantly, the report divides contributions into detailed categories based on the amount, distinguishing between unitemized contributions of $50.00 or less and larger contributions, which require itemization. A section devoted to the summary of receipts and expenditures allows for a clear, financial snapshot, highlighting the total monetary contributions, expenditures, and the ending cash balance. The report underscores the importance of accountability through the affidavit section, requiring a sworn statement from the filer attesting to the accuracy and completeness of the information provided. Thus, the Campaign Finance Report serves as a vital tool in promoting financial integrity and public trust in the political process.

QuestionAnswer
Form NamePa Campaign Form
Form Length18 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 30 sec
Other namescommonwealth of pa campaign finance report, pennsylvania campaign finance, pa campaign finance report pdf, pennsylvania campaign finance reports

Form Preview Example

Commonw ealth of Pennsylvania - Campaign Finance Report

(Note: This report must be clear and legible. It should be typed)

 

Filer Identification

 

 

 

 

Report Filed By

 

 

Candidate

 

 

 

 

 

Committee

 

 

 

 

Lobbyist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number

 

 

 

 

( M ark X)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Filing Committee, Candidate or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lobbyist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Report (Place x under report t ype)

 

1- 6t h Tuesday

 

2- 2 nd Friday

3- 30 Day Post

4

- 6 t h Tuesday

 

5- 2nd Friday

 

6- 30 Day Post

 

7- Annual

 

Special 2nd Friday

 

Special 30 Day

 

 

Pre-Primary

 

Pre-Primary

Primary

Pre- Election

Pre- Electio

n

 

Election

 

 

 

 

 

 

 

Pre-Election

 

Post -Election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Of Election

 

 

 

 

 

 

 

Year

 

 

 

 

 

 

Amendment

 

 

 

 

 

 

 

Termination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(M M / DD/ YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Report

 

 

 

 

 

 

 

Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of Receipts and

From Date

 

 

 

 

To Date

 

 

 

 

 

 

 

 

 

For Office Use Only

 

 

 

 

 

Expenditures

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Amount Brought Forw ard From Last Report

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Total M onetary Contributions and Receipts

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(From Schedule I)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Total Funds Available

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Sum of Lines A and B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. Total Expenditures

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(From Schedule III)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. Ending Cash Balance

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Subtract Line D from Line C)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. Value of In-Kind Contributions Received

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(From Schedule II)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G. Unpaid Debts and Obligations

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(From Schedule IV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Affidavit Sect ion

Part 1- If t his is a Commit t ee report , t reasurer sign here. If t his is a Candidat e report , candidat e sign here.

I sw ear (or affirm) t hat t his report , including t he at t ached schedules on paper, is t o t he best of my know ledge and belief t rue, correct and complet e.

Sw orn t o and subscribed before me t his

_________day of __________________20__________

____________________________________________

Signat ure

M y Commission expires_________________________

M O.

DAY

YR.

____________________________________________________

Signat ure of Person Submit t ing report

____________________________________________________

 

Print ed Name

_____________

___________________________

Area Code

Dayt ime Telephone Number

Part II- If t his is a report of a Candidate's Authorized Committee, candidat e shall sign here.

I sw ear (or affirm) t hat t o t he best of my know ledge and belief t his polit ical commit t ee has not violat ed any provisions of t he Act of June 3, 1937 (P.L. 1333, NO.320) as amended.

Sw orn t o and subscribed before me t his

_________day of __________________20__________

____________________________________________

Signat ure

M y Commission expires_________________________

M O.

DAY

YR.

____________________________________________________

Signat ure of Candidat e

____________________________________________________

 

Print ed Name

_____________

___________________________

Area Code

Dayt ime Telephone Number

SCHEDULE I

Contributions and Receipts

Detailed Summary Page

Filer Identification Number

1.Unitemized Contributions and Receipts-$50.00 or Less per Contributor

Tot al for t he report ing period

(1)

$

2. Contributions of $50.01 to $250.00 (From Part A and Part B)

 

Cont ribut ions Received from Polit ical Commit t ees (Part A)

 

$

 

 

 

 

 

 

 

All Ot her Cont ribut ions (Part B)

 

$

 

 

 

 

 

 

 

Tot al for t he report ing period

(2)

$

 

 

 

 

 

 

 

3. Contributions Over $250.00 (From Part C and Part D)

 

 

 

 

 

 

 

 

 

Cont ribut ions Received from Polit ical Commit t ees (Part C)

 

$

 

 

 

 

 

 

 

All Ot her Cont ribut ions (Part D)

 

$

 

 

 

 

 

 

 

Tot al for t he report ing period

(3)

$

 

 

 

 

 

 

 

4. Other Receipts-Refunds, Interest Earned, Returned Checks, ETC. (From Part E)

 

 

 

 

 

 

 

 

 

Tot al for t he report ing period

(4)

$

 

 

 

 

 

 

 

Tot al M onet ary Cont ribut ions and Receipt s during t his report ing period (Add and

 

$

 

ent er am ount t ot als from Boxes 1, 2, 3 and 4; also ent er t his am ount on Page 1, Report Cover Page, It em B)

PART A

Contributions Received From Political Committees

$50.01 TO $250.00

Use this Part to itemize only contributions received from Political Committees

w ith an aggregate value from $50.01 TO $250.00 in the reporting period.

Filer Identification Number

Amount

 

Full Name of Contributing

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributing

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributing

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributing

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributing

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributing

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART B

All Other Contributions

$50.01 TO $250

Use this Part to itemize all other contributions w ith an aggregate value from

$50.01 TO $250 in the reporting period.

(Exclude contributions from political committees reported in Part A.)

Filer Identification Number:

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART C

Contributions Received From Political Committees

Over $250.00

Use this Part to itemize only contributions received from Political Committees

w ith an aggregate value over $250.00 in the reporting period.

Filer Identification Number:

 

Full Name of

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

Contributing Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

Contributing Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

Contributing Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

Contributing Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

Contributing Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

Contributing Committee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART D

All Other Contributions

Over $250.00

Use this Part to itemize all other contributions w ith an aggregate value over $250.00 in the reporting period.

(Exclude contributions from political committees reported in Part C)

Filer Identification Number:

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer M ailing Address /

 

 

 

 

 

 

 

 

 

Principal Place of Business

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer M ailing Address /

 

 

 

 

 

 

 

 

 

Principal Place of Business

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer M ailing Address /

 

 

 

 

 

 

 

 

Principal Place of Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

Zip Code

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer M ailing Address /

 

 

 

 

 

 

 

 

 

Principal Place of Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART E

Other Receipts

REFUNDS, INTREST INCOM E, RETURNED CHECKS, ETC.

Use this Part to report refunds received, interest earned, returned checks and prior expenditures that w ere returned to the filer.

Filer Identification Number:

Full Name

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receipt

Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receipt

Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receipt

Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receipt

Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receipt

Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receipt

Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHEDULE ll

IN-KIND CONTRIBUTIONS AND VALUABLE THINGS RECIEVED

USE THIS SCHEDULE TO REPORT ALL IN-KIND CONTRIBUTIONS OF VALUABLE THINGS DURING THE REPORTING PERIOD

DETAILED SUM M ARY PAGE

Filer Ident ificat ion Number:

1. UNITEM IZED IN-KIND CONTRIBUTIONS RECEIVED-VALUE OF $50.00 OR LESS PER CONTRIBUTOR

TOTAL for t he report ing period

(1)

$

2. IN-KIND CONTRIBUTIONS RECEIVED-VALUE OF $50.01 TO $250.00 (FROM PART F)

TOTAL for t he report ing period

(2)

$

3. IN-KIND CONTRIBUTION RECEIVED-VALUE OVER $250.00 (FROM PART G)

TOTAL for t he report ing period

(3)

$

TOTAL VALUE OF IN-KIND CONTRIBUTIONS DURING THIS REPORTING PERIOD (Add and ent er amount t ot als from boxes 1, 2, and 3; also ent er on Page 1, Report Cover Page, It em F)

$

SCHEDULE II

PART F

In-Kind Contributions Received

VALUE OF $50.01 TO $250

Filer Identification Number:

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of Contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of Contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of Contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of Contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of Contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHEDULE II

Part G

In-Kind Contributions Received

VALUE OVER $250

Filer Identification Number:

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer M ailing Address / Principal

 

 

 

 

 

 

 

 

Description

 

 

 

 

 

 

Place of Business

 

 

 

 

 

 

 

 

 

 

 

of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer M ailing Address / Principal

 

 

 

 

 

 

 

 

Description

 

 

 

 

 

 

Place of Business

 

 

 

 

 

 

 

 

 

 

 

of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contribution

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer M ailing Address / Principal

 

 

 

 

 

 

 

 

Description

 

 

 

 

 

 

Place of Business

 

 

 

 

 

 

 

 

 

 

 

of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Contributor

 

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip Code

 

 

Date [M M / DD/ YYYY]

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer M ailing Address / Principal

 

 

 

 

 

 

 

 

Description

 

 

 

 

 

 

Place of Business

 

 

 

 

 

 

 

 

 

 

 

of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contribution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHEDULE III

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Statement of Expenditures

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Filer Identification Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To W hom Paid

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

 

Street Address

 

 

 

 

 

 

 

Description of Expenditure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

To W hom Paid

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

 

Street Address

 

 

 

 

 

 

 

Description of Expenditure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

To W hom Paid

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

 

 

 

Street Address

 

 

 

 

 

 

 

Description of Expenditure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To W hom Paid

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

 

 

Street Address

 

 

 

 

 

 

 

Description of Expenditure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

To W hom Paid

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

 

 

 

Street Address

 

 

 

 

 

 

 

Description of Expenditure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

To W hom Paid

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

 

 

 

Street Address

 

 

 

 

 

 

 

Description of Expenditure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

To W hom Paid

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

 

 

Street Address

 

 

 

 

 

 

 

Description of Expenditure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

To W hom Paid

 

 

 

 

 

 

 

 

 

Date [M M / DD/ YYYY]

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

 

 

Street Address

 

 

 

 

 

 

 

Description of Expenditure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHEDULE IV

Statement of Unpaid Debts

Use this Section to itemize all unpaid debts and obligations w hich are outstanding at the end of the reporting period.

Filer Identification Number:

Name of Creditor

 

 

 

 

 

 

 

 

 

Outstanding Balance of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

DATE DEBT INCURRED

$

 

 

 

 

 

 

 

 

[M M / DD/ YYYY]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

Description of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Creditor

 

 

 

 

 

 

 

 

 

Outstanding Balance of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

DATE DEBT INCURRED

$

 

 

 

 

 

 

 

 

[M M / DD/ YYYY]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

Description of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Creditor

 

 

 

 

 

 

 

 

 

Outstanding Balance of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

DATE DEBT INCURRED

$

 

 

 

 

 

 

 

 

[M M / DD/ YYYY]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

Description of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Creditor

 

 

 

 

 

 

 

 

 

Outstanding Balance of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

 

DATE DEBT INCURRED

$

 

 

 

 

 

 

 

 

[M M / DD/ YYYY]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

Description of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Creditor

 

 

 

 

 

 

 

 

 

Outstanding Balance of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

DATE DEBT INCURRED

$

 

 

 

 

 

 

 

 

[M M / DD/ YYYY]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

Description of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Creditor

 

 

 

 

 

 

 

 

 

Outstanding Balance of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

House #

 

Street Address

 

 

DATE DEBT INCURRED

$

 

 

 

 

 

 

 

 

[M M / DD/ YYYY]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

Description of Debt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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