POLITICAL COMMITTEE’S REPORT
OF RECEIPTS AND DISBURSEMENTS
-INITIATIVE MEASURE-
Name of Committee _________________________________________________________
Address of Committee (Include city, state, zip) _________________________________
Telephone ___________________________ (Fax)______________________________
Name of Director______________________ Name of Treasurer ___________________
Check here if above is different from previous report.
TYPE OF REPORT
• • • • CHECK THE CATEGORY OF REPORT YOU ARE SUBMITTING • • • •
_____ Monthly Report for the month of _________________________ , year ________.
As required by law
Required to terminate
Termination Report (Committee will no longer accept campaign contributions or make
___
reporting obligations
campaign expenditures and has no outstanding campaign debt or obligations.)
IMPORTANT
(1)
Monthly reports are mandatory, even if no contributions or expenditures have transpired. In such case, the committee shall submit a report
indicating “0” for total amount of reported contributions and expenditures during this period, along with the cash balance.
th
(2)
Until a committee files its termination report, it must continue to file monthly reports on the 10
day of every month.
UNITEMIZED CONTRIBUTIONS AND DISBURSEMENTS - $200 OR LESS
This Period
Calendar year-to-date
Total amount of reported unitemized contributions
$
$
Total amount of reported unitemized disbursements
$
$
ITEMIZED CONTRIBUTIONS AND DISBURSEMENTS – EXCEEDING $200
This Period
Calendar year-to-date
Total amount of reported itemized contributions
$
$
Total amount of reported itemized disbursements
$
$
CASH ON HAND……………… $___________________________
$__________________________
BEGINNING OF PERIOD
END OF PERIOD
I certify that I have examined this report and to the best of my knowledge and belief it is true, accurate, and complete.
___________________________________________________
_______________________________
(Signature of Director or Treasurer)
(Date)
Authority: Refer to Miss. Code Ann. §23-17-48 TO §23-17-53 (1972) for statutory requirements.
Penalties: Failure to submit required reports, or failure to submit reports in accordance with statutory deadlines, or failure to submit valid reports shall
result in prosecution in accordance with Miss. Code Ann. §23-17-61 (1972).
Return this form to: ERIC CLARK, Secretary of State, P.O. Box 136, Jackson, MS 39205 or fax to 601-359-1499.
SS 93-59 02/99