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Affirmation Statement For Limited Liability Company (Llc) Contributions - Colorado Secretary Of State

Affirmation Statement for Limited Liability Company (LLC) Contributions

This form should be retained by the receiving committee for at least one year following the end of the applicable election cycle.

Date of Contribution: ____________________________

Contribution Amount: $__________________________________

Contribution Type:

Monetary

Non-Monetary

Description if non-monetary: _____________________________

Name of LLC making Contribution: ______________________________________________________________________________

Address: ___________________________________ City: ____________________________ State: __________

Zip: _______

Name of Recipient Committee:

______________________________________________________________________________

Recipient Committee Type:

Candidate committee

Political committee

Political party

I _____________________________________, individual acting on behalf of the above named Limited Liability Company, affirm

(Print Individual Name)

that the LLC is authorized to make this contribution under Colorado State law.

______________________________________________________________

Signature of Individual Acting on behalf of the LLC

Names and Address of All Individual LLC Members

LLC Member(s)

Address

City

State

Zip

Attributed

Employer &

Contribution

Occupation (

if applicable)

Example:

10001 E. Mississippi Ave.

Colorado Springs

80901

$100

XYZ Printing

Jane Doe

Pressman

Colorado Secretary of State Sample Form

Rev. 12/09

Affirmation Statement For Limited Liability Company (Llc) Contributions - Colorado Secretary Of State