Form 22 Matching Funds Request For Qualification Or Claim For Payment
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2City Ethics Commission
200 North Spring Street
City Hall — 24th Floor
Los Angeles, CA 90012
(213) 978-1960
Candidate Name (Last, First, Middle)
Date of Request/Claim
Committee Name
ID Number
Office Sought (include district number if applicable)
Date of Election
Type of Form
Qualification Request
Original filing
Amended filing (original signed on ______________; last amendment signed on _____________.)
Payment Claim
Original filing
Amended filing (original signed on ______________; last amendment signed on _____________.)
Amount of matching funds claimed through this form:
$ _____________________________________
Qualification Request and Payment Claim
Original filing
Amended filing (original signed on ______________; last amendment signed on _____________.)
Amount of matching funds claimed through this form:
$ _____________________________________
Documentation Requirements
For qualification requests, you must submit the following:
1. The table on page 2 of this form, identifying:
A. Contributions from individuals residing within the City and totaling the applicable amount in LAMC § 49.7.23(C)(1)(a); and
B. For City Council candidates, contributions of $5 or more from at least 200 individuals residing in the district for which
office is sought (indicated by checking “In District” column).
2. Documentation supporting each contribution (copies of checks, credit card receipts, contributor verification forms, etc.).
For payment claims, you must submit the following:
1. The table on page 2 of this form, identifying contributions from individuals residing within the City and representing the
minimum amount required by LAMC § 49.7.28(A).
2. Documentation supporting each contribution (copies of checks, credit card receipts, contributor verification forms, etc.).
Certifications
I declare under penalty of perjury under the laws of the City of Los Angeles and the state of California that all contributions have
been deposited into the campaign checking account of the committee identified above and that, to the best of my knowledge
and belief, this form and all supporting documents are true and complete and all contributions are from City residents.
Candidate Signature
Date
Treasurer Signature
Date
Treasurer Name
Ethics Commission Use Only
Rate
Claim # _______
1:1
Approved payment for this claim:
$
2:1/4:1
Amounts previously paid:
$
Total payments to date:
$
Verified
Los Angeles Municipal Code §§ 49.7.23, 49.7.28
Page 1 of 2
October 2014
Los Angeles Administrative Code §§ 24.32(b), 24.34
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