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

(Rev. November 2013)

Information about Form 8872 and its instructions is available at

▶

Department of the Treasury

Do not enter Social Security numbers on this form as it may be made public.

Internal Revenue Service

▶

For the period beginning

, 20

and ending

, 20

Check applicable boxes:

Initial report

Change of address

Amended report

Final report

Employer identification number

Name of organization

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

City or town, state or province, country, and ZIP or foreign postal code

Email address of organization

4 Date organization was formed

Name of custodian of records

5b Custodian's address

Name of contact person

6b 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 or province, country, and ZIP or foreign postal code

Type of report (check only one box)

First quarterly report (due by April 15)

Monthly report for the month of:

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

December report, which is due by January 31)

Second quarterly report (due by July 15)

Third quarterly report (due by October 15)

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

election)

Year-end report (due by January 31)

(1)

Type of election:

(2)

Date of election:

(3)

Mid-year report (Non-election year only–due by July 31)

For the state of:

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

election)

(1)

Date of election:

(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

(Rev. 11-2013)