Form 48492 - Supplemental "Large Contribution"Report By A Candidate'S Committee

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SUPPLEMENTAL “LARGE CONTRIBUTION”REPORT
(CFA-11)
BY A CANDIDATE’S COMMITTEE
($1,000 CONTRIBUTIONS OR MORE)
FILE NUMBER
State Form 48492 (R3/11-05)
Indiana Election Commission (IC 3-9-5-20.1; 3-9-5-22)
INSTRUCTIONS: Only candidates receiving a “large contribution” are required to file this report.
Please type or print legibly IN BLACK INK all information on this form. For assistance in
TOTAL PAGES IN ENTIRE CFA-11
completing this form, see instructions on the reverse side.
REPORT
COMMITTEE INFORMATION
1. Full Name of Candidate (include any nickname)
Check if this is a new name
2. Committee Telephone Number
(
)
3. Mailing Address (address where all campaign finance correspondence is received)
Check if this is a new address
4. City
State
ZIP Code
5. Party Affiliation or If Independent Candidate
6. Office Sought (include district number, if any. Not required for exploratory committee.)
7. County of Residence
8. Reporting Period:
From:
Through:
For classification, enter INDV for individual; PAC for political action committee: CORP for corporation; LAB for labor organization; NONE for all entries which are not one of the above categories.
COLUMN A
DATE RECEIVED
CONTRIBUTOR’S FULL NAME AND OCCUPATION
TYPE OF CONTRIBUTION
AMOUNT OF
FULL MAILING ADDRESS
OR OTHER RECEIPT
CONTRIBUTION
(street, number, city, state, ZIP code)
RECEIVED BY
Classification
1.
Contributions:
Direct
In-Kind (describe)
Other Receipts:
Interest
Loan
Misc (specify)
Contributor’s Occupation (if applicable) ____________________________________________
Contributions:
Classification
2.
Direct
In-Kind (describe)
Other Receipts:
Interest
Loan
Misc (specify)
Contributor’s Occupation (if applicable) ____________________________________________
Classification
3.
Contributions:
Direct
In-Kind (describe)
Other Receipts:
Interest
Loan
Misc (specify)
Contributor’s Occupation (if applicable) ____________________________________________
CERTIFICATION
FOR OFFICE USE ONLY
I CERTIFY THAT I HAVE EXAMINED THIS STATEMENT. TO THE BEST OF MY KNOWLEDGE AND BELIEF IT IS
TRUE, CORRECT AND COMPLETE.
Date (MM–DD–YY)
Signature of Treasurer
Title
Signature of Candidate (if applicable)
Date (MM–DD–YY)
Warning:
Any information contained in this report may not be copied for sale or used for any commercial purpose. (IC 3-9-4-5) A
person who knowingly files a fraudulent report commits a Class D felony. (IC 3-14-1-13) A person who fails to file a complete or accurate
report as required by the Indiana Campaign Finance Law commits a Class B misdemeanor (IC 3-14-1-14), and may be subject to civil
penalties. (IC 3-9-4-16, IC 3-9-4-17, and IC 3-9-4-18)

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