Form 31-A-2 - Statement Of Other Income
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Statement of Other Income
Form 31-A-2
R.C. 3517.10(B)
Full Name of Committee
Full Name of Contributor
Registration Number, if PAC
Street Address
Type*
Form (Cash, Check, etc.)
Date (MM/DD/YYYY)
Refund
City
State
Zip Code
Amount
OH
Full Name of Contributor
Registration Number, if PAC
Street Address
Type*
Form (Cash, Check, etc.)
Date (MM/DD/YYYY)
Refund
City
State
Zip Code
Amount
OH
Full Name of Contributor
Registration Number, if PAC
Street Address
Type*
Form (Cash, Check, etc.)
Date (MM/DD/YYYY)
Refund
City
State
Zip Code
Amount
OH
Full Name of Contributor
Registration Number, if PAC
Street Address
Type*
Form (Cash, Check, etc.)
Date (MM/DD/YYYY)
Refund
City
State
Zip Code
Amount
OH
Full Name of Contributor
Registration Number, if PAC
Street Address
Type*
Form (Cash, Check, etc.)
Date (MM/DD/YYYY)
Refund
City
State
Zip Code
Amount
OH
* Place the two letter code in the Type block (one letter per square) which indicates the nature of the Other Income Received; RE for a refund, uncashed check or
the committee’s own insufficient funds check received, IN for any investment or interest income earned by the committee, SA for the sale of committee assets, or
LN for payments received on a loan made.
Page Total $
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