Form 8872 Political Organization Report on Contributions and Expen

Form

8872

(November 2002)

Political Organization
Report of Contributions and Expenditures

Department of the Treasury
Internal Revenue Service

OMB No. 1545-1696

See Seperate instructions.

A

For the period beginning

,20

B
1

Check applicable boxes:
Name of organization

2

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

Intial report

and ending

Change of address

, 20

Amended report
Final report
Employer identification number

City or town, state, and ZIP code
3

E-mail address of organization

4 Date organization was formed

5a Name of custodian of records

5b Custodian’s address

6a Name of contact person

6b Contact person’s address

7

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

8

Type of report (check only one box)
f
a

First quarterly report (due by April 15)

b

Second quarterly report (due by July 15)

g

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)
Pre-election report (due by the 12th or 15th day before the election)
(1) Type of election:

c

Third quarterly report (due by October 15)

d

Year-end report (due by January 31)

e

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

(2) Date of election:
(3) For the state of:
h

Post-general election report (due by the 30th day after general election)
(1) Date of election:
(2) For the state of:

9

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

9

10

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

10

Sign
Here

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.

Signature of authorized official

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 30406G

Date
Form

8872

(11-2002)

Form 8872 (11-2002)

Schedule A

Itemized Contributions

Schedule A page
of
Employer identification number

Name of organization
Contributor’s name, mailing address and ZIP code

Name of contributor’s employer

Amount of contribution

Contributor’s occupation

Contributor’s name, mailing address and ZIP code

Aggregate contributions


$
year-to-date
Name of contributor’s employer

$
Date of contribution
Amount of contribution

Contributor’s occupation

Contributor’s name, mailing address and ZIP code

Aggregate contributions


year-to-date
$
Name of contributor’s employer

$
Date of contribution
Amount of contribution

Contributor’s occupation

Contributor’s name, mailing address and ZIP code

Aggregate contributions


$
year-to-date
Name of contributor’s employer

$
Date of contribution
Amount of contribution

Contributor’s occupation

Contributor’s name, mailing address and ZIP code

Aggregate contributions


year-to-date
$
Name of contributor’s employer

$
Date of contribution
Amount of contribution

Contributor’s occupation

Contributor’s name, mailing address and ZIP code

Aggregate contributions


year-to-date
$
Name of contributor’s employer

$
Date of contribution
Amount of contribution

Contributor’s occupation

Contributor’s name, mailing address and ZIP code

Aggregate contributions


year-to-date
$
Name of contributor’s employer

$
Date of contribution
Amount of contribution

Contributor’s occupation

Contributor’s name, mailing address and ZIP code

Aggregate contributions


$
year-to-date
Name of contributor’s employer

$
Date of contribution
Amount of contribution

Contributor’s occupation

Contributor’s name, mailing address and ZIP code

Aggregate contributions


$
year-to-date
Name of contributor’s employer

$
Date of contribution
Amount of contribution

Contributor’s occupation

Aggregate contributions


year-to-date

$
Date of contribution
$

Subtotal of contributions reported on this page only. Enter here and also include this amount in the total on line 9


of Form 8872

$
Form

8872

(11-2002)

Form 8872 (11-2002)

Schedule B

Itemized Expenditures

Schedule B page
of
Employer identification number

Name of organization
Recipient’s name, mailing address and ZIP code

Name of recipient’s employer

Amount of expenditure

Recipient’s occupation

$
Date of expenditure

Name of recipient’s employer

Amount of expenditure

Recipient’s occupation

$
Date of expenditure

Name of recipient’s employer

Amount of expenditure

Recipient’s occupation

$
Date of expenditure

Name of recipient’s employer

Amount of expenditure

Recipient’s occupation

$
Date of expenditure

Name of recipient’s employer

Amount of expenditure

Recipient’s occupation

$
Date of expenditure

Name of recipient’s employer

Amount of expenditure

Recipient’s occupation

$
Date of expenditure

Purpose of expenditure

Recipient’s name, mailing address and ZIP code

Purpose of expenditure

Recipient’s name, mailing address and ZIP code

Purpose of expenditure

Recipient’s name, mailing address and ZIP code

Purpose of expenditure

Recipient’s name, mailing address and ZIP code

Purpose of expenditure

Recipient’s name, mailing address and ZIP code

Purpose of expenditure

Subtotal of expenditures reported on this page only. Enter here and also include this amount in the total on


line 10 of Form 8872

$
Form

8872

(11-2002)