Check if addi onal pages
have been a ached.
Owed to Whom
Total Unpaid Bills:
I, _________________________________________, swear or aﬃrm that the a ached statement is
true and accurate, to the best of my knowledge, for all ﬁnancial transac ons occurring within the
period covered by this statement, as required by West Virginia Code §3‐8‐5a.
_______________________________________________________ Signature of Candidate, Financial Agent or Treasurer
Date ___________________, 20______
Oﬃce Use Only
Received By: __________________