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Commonwealth of Pennsylvania - Campaign Finance Report

(Note: This report must be clear and legible. It should be typed)

Filer Identification
Number
Name of Filing Committee, Candidate or
Lobbyist
Street Address

Report Filed By
( Mark X)

City

Candidate

Committee

State

Zip Code

Lobbyist

Type of Report (Place x under report type)

1- 6th Tuesday 2- 2 nd Friday 3- 30 Day Post 4- 6 th Tuesday 5- 2nd Friday 6- 30 Day Post
Pre-Primary
Pre-Primary Primary
Pre- Election Pre- Election Election

Date Of Election
(MM/DD/YYYY)
Summary of Receipts and
Expenditures

Year
From Date

Amendment
Report
To Date

A. Amount Brought Forward From Last Report

B. Total Monetary Contributions and Receipts

(From Schedule I)
C. Total Funds Available
(Sum of Lines A and B)
D. Total Expenditures
(From Schedule III)
E. Ending Cash Balance
(Subtract Line D from Line C)
F. Value of In-Kind Contributions Received
(From Schedule II)
G. Unpaid Debts and Obligations
(From Schedule IV)

7- Annual

Special 2nd Friday

Pre-Election

Special 30 Day
Post-Election

Termination
Report
For Office Use Only

$
$
$
$
$

Affidavit Section
Part 1- If this is a Committee report, treasurer sign here. If this is a Candidate report, candidate sign here.
I swear (or affirm) that this report, including the attached schedules on paper, is to the best of my knowledge and belief true, correct and complete.
Sworn to and subscribed before me this
_________day of__________________20__________
____________________________________________
Signature

____________________________________________________
Signature of Person Submitting report
____________________________________________________
Printed Name

My Commission expires_________________________
MO.
DAY
YR.

_____________
Area Code

___________________________
Daytime Telephone Number

Part II- If this is a report of a Candidate's Authorized Committee, candidate shall sign here.
I swear (or affirm) that to the best of my knowledge and belief this political committee has not violated any provisions of the Act of June 3, 1937 (P.L. 1333, NO.320) as
amended.
Sworn to and subscribed before me this
_________day of__________________20__________
____________________________________________
Signature

____________________________________________________
Signature of Candidate
____________________________________________________
Printed Name

My Commission expires_________________________
MO.
DAY
YR.

_____________
Area Code

___________________________
Daytime Telephone Number

SCHEDULE I

Contributions and Receipts

Detailed Summary Page
Filer Identification Number

1.Unitemized Contributions and Receipts-$50.00 or Less per Contributor

Total for the reporting period

(1)

2. Contributions of $50.01 to $250.00 (From

Part A and Part B)
Contributions Received from Political Committees (Part A)

All Other Contributions (Part B)

$
Total for the reporting period

(2)

3. Contributions Over $250.00 (From Part C and Part D)

Contributions Received from Political Committees (Part C)

All Other Contributions (Part D)

$
Total for the reporting period

(3)

(4)

Total Monetary Contributions and Receipts during this reporting period (Add and
enter amount totals from Boxes 1, 2, 3 and 4; also enter this amount on Page 1, Report
Cover Page, Item B)

4. Other Receipts-Refunds, Interest Earned, Returned Checks, ETC. (From Part E)

Total for the reporting period

PART A

Contributions Received From Political Committees

$50.01 TO $250.00
Use this Part to itemize only contributions received from Political Committees
with an aggregate value from $50.01 TO $250.00 in the reporting period.

Filer Identification Number

Amount
Full Name of Contributing
Committee

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributing

Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributing

Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributing

Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributing

Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

House #

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Full Name of Contributing

Committee
House #

Street Address

City

State

Street Address

City

State

Zip Code

Street Address

City

City

Zip Code

State

Zip Code

Street Address
State

Zip Code

PART B

All Other Contributions

$50.01 TO $250
Use this Part to itemize all other contributions with an aggregate value from
$50.01 TO $250 in the reporting period.
(Exclude contributions from political committees reported in Part A.)
Filer Identification Number:

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Street Address

City

City

Zip Code

State

Zip Code

Street Address
State

Zip Code

PART C

Contributions Received From Political Committees

Over $250.00
Use this Part to itemize only contributions received from Political Committees
with an aggregate value over $250.00 in the reporting period.

Filer Identification Number:

Full Name of
Contributing Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of
Contributing Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of
Contributing Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of
Contributing Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of
Contributing Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of
Contributing Committee

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Street Address

City

City

Zip Code

State

Zip Code

Street Address
State

Zip Code

PART D

All Other Contributions

Over $250.00
Use this Part to itemize all other contributions with an aggregate value over $250.00 in the reporting period.
(Exclude contributions from political committees reported in Part C)
Filer Identification Number:

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Zip Code

Employer Name

Occupation

Employer Mailing Address /

Principal Place of Business
Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Zip Code

Employer Name

Occupation

Employer Mailing Address /

Principal Place of Business
Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Zip Code

Employer Name

Occupation

Employer Mailing Address /

Principal Place of Business
Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City
Employer Name
Employer Mailing Address /
Principal Place of Business

State

Zip Code

Occupation

PART E

Other Receipts

REFUNDS, INTREST INCOME, RETURNED CHECKS, ETC.

Use this Part to report refunds received, interest earned, returned checks and prior expenditures that were returned to the filer.
Filer Identification Number:

Full Name
House #

Street Address

City

State

Zip
Code

Date [MM/DD/YYYY]

State

Zip
Code

Date [MM/DD/YYYY]

State

Zip
Code

Date [MM/DD/YYYY]

State

Zip
Code

Date [MM/DD/YYYY]

State

Zip
Code

Date [MM/DD/YYYY]

State

Zip
Code

Date [MM/DD/YYYY]

Receipt Description
Full Name
House #

Street Address

City
Receipt Description
Full Name
House #

Street Address

City

Receipt Description
Full Name
House #

Street Address

City
Receipt Description
Full Name
House #

Street Address

City
Receipt Description
Full Name
House #
City
Receipt Description

Street Address

SCHEDULE ll

IN-KIND CONTRIBUTIONS AND VALUABLE THINGS RECIEVED

USE THIS SCHEDULE TO REPORT ALL IN-KIND CONTRIBUTIONS OF VALUABLE THINGS DURING THE REPORTING PERIOD
DETAILED SUMMARY PAGE
Filer Identification Number:

1.

UNITEMIZED IN-KIND CONTRIBUTIONS RECEIVED-VALUE OF $50.00 OR LESS PER CONTRIBUTOR

TOTAL for the reporting period

2.

IN-KIND CONTRIBUTIONS RECEIVED-VALUE OF $50.01 TO $250.00 (FROM PART F)

TOTAL for the reporting period

3.

(1)

(2)

IN-KIND CONTRIBUTION RECEIVED-VALUE OVER $250.00 (FROM PART G)

TOTAL for the reporting period

(3)

TOTAL VALUE OF IN-KIND CONTRIBUTIONS DURING THIS REPORTING

PERIOD (Add and enter amount totals from boxes 1, 2, and 3; also enter
on Page 1, Report Cover Page, Item F)

SCHEDULE II
PART F

In-Kind Contributions Received

VALUE OF $50.01 TO $250

Filer Identification Number:

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Zip Code

Description of Contribution

Street Address

City

State

Zip Code

Description of Contribution

Street Address

City

State

Zip Code

Description of Contribution

Street Address

City

State

Zip Code

Description of Contribution

Street Address

City
Description of Contribution

State

Zip Code

SCHEDULE II
Part G

In-Kind Contributions Received

VALUE OVER $250

Filer Identification Number:

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Zip Code

Employer Name

Occupation

Employer Mailing Address / Principal

Place of Business

Description
of
Contribution

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Zip Code

Employer Name

Occupation

Employer Mailing Address / Principal

Place of Business

Description
of
Contribution

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Zip Code

Employer Name

Occupation

Employer Mailing Address / Principal

Place of Business

Description
of
Contribution

Full Name of Contributor

Date [MM/DD/YYYY]

House #

Date [MM/DD/YYYY]

Date [MM/DD/YYYY]

Street Address

City

State

Zip Code

Employer Name

Occupation

Employer Mailing Address / Principal

Place of Business

Description
of
Contribution

SCHEDULE III

Statement of Expenditures
Filer Identification Number:

To Whom Paid
House #

Date [MM/DD/YYYY]

Description of Expenditure

Street Address

City

State

Zip
Code

To Whom Paid
House #

Date [MM/DD/YYYY]

State

Zip
Code

To Whom Paid
House #

Date [MM/DD/YYYY]

State

Zip
Code

To Whom Paid
House #

Date [MM/DD/YYYY]

State

Zip
Code

To Whom Paid
House #

Date [MM/DD/YYYY]

State

Zip
Code

To Whom Paid
House #

Date [MM/DD/YYYY]

State

Zip
Code

To Whom Paid
House #

Date [MM/DD/YYYY]

State

Zip
Code

To Whom Paid
House #
City

Description of Expenditure

Street Address

City

Description of Expenditure

Street Address

City

Description of Expenditure

Street Address

City

Description of Expenditure

Street Address

City

Description of Expenditure

Street Address

City

Description of Expenditure

Street Address

City

Date [MM/DD/YYYY]

Description of Expenditure

Street Address
State

Zip
Code

SCHEDULE IV

Statement of Unpaid Debts

Use this Section to itemize all unpaid debts and obligations which are outstanding at the end of the reporting period.
Filer Identification Number:

Name of Creditor
House #

Outstanding Balance of Debt

DATE DEBT INCURRED
[MM/DD/YYYY]

Street Address

City

State

Zip
Code

Description of Debt
Name of Creditor
House #

Outstanding Balance of Debt

DATE DEBT INCURRED
[MM/DD/YYYY]

Street Address

City

State

Zip
Code

Description of Debt
Name of Creditor
House #

Outstanding Balance of Debt

DATE DEBT INCURRED
[MM/DD/YYYY]

Street Address

City

State

Zip
Code

Description of Debt
Name of Creditor
House #

Outstanding Balance of Debt

DATE DEBT INCURRED
[MM/DD/YYYY]

Street Address

City

State

Zip
Code

Description of Debt
Name of Creditor
House #

Outstanding Balance of Debt

DATE DEBT INCURRED
[MM/DD/YYYY]

Street Address

City

State

Description of Debt

Zip
Code

Name of Creditor
House #

City
Description of Debt

Outstanding Balance of Debt

DATE DEBT INCURRED
[MM/DD/YYYY]

Street Address

State

Zip
Code