Ss 93-59 Political Committee'S Report Of Receipts And Disbursements Nitiative Measure Form - Eric Clark Page 2
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1
2
3Name of Candidate or Committee _________________________________
Reporting period_______________________ through _________________
ITEMIZED RECEIPTS
Amount of each
A. Source:
Corporation
PAC
Individual
Loan
Date
receipt
Other (please specify)__________________________________
(
Year)
this period
Mo., Day,
$
___ / ___ / ___
Full name
Mailing Address
$
___ / ___ / ___
City, State, Zip Code
$
___ / ___ / ___
Name of Employer (Required)
$
___ / ___ / ___
Occupation (Required)
Aggregate
$
year–to-date
Amount of each
B. Source:
Corporation
PAC
Individual
Loan
Date
receipt
Other (please specify)__________________________________
(
Year)
this period
Mo., Day,
Full name
$
___ / ___ / ___
Mailing Address
$
___ / ___ / ___
City, State, Zip Code
$
___ / ___ / ___
Name of Employer (Required)
$
___ / ___ / ___
Occupation (Required)
Aggregate
$
year–to-date
Amount of each
C. Source:
Corporation
PAC
Individual
Loan
Date
receipt
Other (please specify)_________________________________
(
Year)
this period
Mo., Day,
$
___ / ___ / ___
Full name
Mailing Address
$
___ / ___ / ___
City, State, Zip Code
$
___ / ___ / ___
Name of Employer (Required)
$
___ / ___ / ___
Occupation (Required)
Aggregate
$
year–to-date
Amount of each
D. Source:
Corporation
PAC
Individual
Loan
Date
receipt
Other (please specify)_________________________________
(
Year)
this period
Mo., Day,
___ / ___ / ___
$
Full name
Mailing Address
___ / ___ / ___
$
City, State, Zip Code
___ / ___ / ___
$
Name of Employer (Required)
___ / ___ / ___
$
Occupation (Required)
Aggregate
$
year–to-date
SS 93-59 02/99
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