Form 8872 - Political Organization Report Of Contributions And Expenditures

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8872

Political Organization

Form

Report of Contributions and Expenditures

OMB No. 1545-1696

(November 2002)

Department of the Treasury

See Seperate instructions.

Internal Revenue Service

For the period beginning

,20

and ending

, 20

Check applicable boxes:

Intial report

Change of address

Amended report

Final report

Name of organization

Employer identification number

Mailing address (P.O. Box or number, street, and room or suite number)

City or town, state, and ZIP code

E-mail address of organization

Date organization was formed

Name of custodian of records

Custodian’s address

Name of contact person

Contact person’s address

Business address of organization (if different from mailing address shown above). Number, street, and room or suite number

City or town, state, and ZIP code

Type of report (check only one box)

Monthly report for the month of:

(due by the 20th day following the month shown above, except the

First quarterly report (due by April 15)

December report, which is due by January 31)

Second quarterly report (due by July 15)

Pre-election report (due by the 12th or 15th day before the election)

(1) Type of election:

Third quarterly report (due by October 15)

(2) Date of election:

(3) For the state of:

Year-end report (due by January 31)

Post-general election report (due by the 30th day after general election)

Mid-year report (Non-election

(1) Date of election:

year only-due by July 31)

(2) For the state of:

Total amount of reported contributions (total from all attached Schedules A)

Total amount of reported expenditures (total from all attached Schedules B)

Under penalties of perjury, I declare that I have examined this report, including accompanying schedules and statements, and to the best of my knowledge

and belief, it is true, correct, and complete.

Sign

Here

Signature of authorized official

Date

8872

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 30406G

Form

(11-2002)