Statement Of Formation
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1
2Statement of Formation
Political Action Committee
W.S. 22-25-101(b)
1.
Who must submit this form?
Two or more persons organized and associated for the purpose of raising, collecting or spending money
to influence the election or defeat of county/local candidates, to support candidate’s committees, political
parties, for support or opposition to any local initiative or referendum petition drive or for the adoption
or defeat of any local ballot proposition.
2.
Committee Information
New Committee Name:______________________________ Date Committee Formed:_______________
Mailing Address:__________________________________ Phone Number:________________________
Website:_____________________________
(Street Address)
__________________________________ Email Address:________________________
(City, State, Zip)
Name of Chairman:_______________________
Name of Treasurer:____________________________
Chairman Address:_______________________
Treasurer Address:___________________________
(Street Address)
(Street Address)
________________________
____________________________
(City, State, Zip)
(City, State, Zip)
(*Note: The chairman and treasurer must be separate individuals.)
3.
Purpose of formation. (Please select one option.)
Committee formed:
To support or oppose the following candidate(s):
Name:___________________ Party Affiliation:______ Office sought by candidate:_________________
To support candidates who support the following issues:_______________________________________
After an election to defray campaign expenses for the following candidate(s):______________________
For the adoption or defeat of the following ballot proposition:___________________________________
For the support of, or opposition to, the following initiative or referendum petition drive:_____________
____________________________________________________________________________________
4.
Signature Required.
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 or Treasurer
Date
5.
Filing Office.
File: Office of your local County Clerk.
o Please visit
https://soswy.state.wy.us/Elections/Docs/WYCountyClerks.pdf
for office
information.
Revised 8/2015
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