Fec Form 1 Statement Of Organization

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11/19/2009 11 : 53
Image# 29993362978
STATEMENT OF
FEC
ORGANIZATION
FORM 1
(See instructions)
Office use only
1.
NAME OF
(Check if name
Example: If typying, type
12FE4M5
COMMITTEE (in full)
is changed)
over the lines
HALEYS PAC
P.O. Box 1186
ADDRESS
(number and street)
(Check if address
is changed)
Jackson
MS
39215
_
CITY
STATE
ZIP CODE
COMMITTEE'S E-MAIL ADDRESS (Please provide only one e-mail address)
(Check if address
(Check if address
is changed)
is changed)
COMMITTEE'S WEB PAGE ADDRESS (URL)
(Check if address
is changed)
2.
M
M
M
M
/
D
D
D
D
/
Y
Y
Y
Y
Y
Y
Y
Y
DATE
1 1
1 6
2 0 0 9
C
3.
FEC IDENTIFICATION NUMBER
C00406314
X
4.
IS THIS STATEMENT
NEW (N)
OR
AMENDED (A)
I certify that I have examined this Statement and to the best of my knowledge and belief it is true, correct and complete
Henry Barbour
Type or Print Name of Treasurer
M
M
/
D
D
/
Y
Y
Y
Y
Henry Barbour
Electronically Filed by
1 1
1 9
2 0 0 9
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
For further information contact:
FEC FORM 1
Use
Federal Election Commission
Toll Free 800-424-9530
(Revised 02/2009)
Only
Local 202-694-1100

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