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INDEPENDENT EXPENDITURES Totaling More Than $100 Made In Support of or in Opposition to Any One Candidate, Political Committee or Measure Full Name: Telephone No.: Mailing Address and Zip Code: TYPE OF REPORT Total Expenditure(s): $ ITEMIZED EXPENDITURES IN EXCESS OF FIFTY DOLLARS $ 2. $ 3. $ 4. $ 5. Date Full Name, Mailing Address and Zip Code of Recipient Amount Candidate/Measure Supported/Opposed Purpose Code(s) $ 1. RETURN THIS FORM TO: Lawerence Denney Secretary of State Elections Division PO Box 83720 Boise, ID 83720-0080 (208) 334-2852 Fax: (208) 334-2282 I, hereby certify that the information in this report is true, complete and correct. Name Signature C-4 Rev. 1/15 B Broadcast Advertising (Radio, TV, Internet & Telephone) E Event Expenses F Food & Refreshments L Literature, Brochures, Printing N Newspaper & Other Periodical Advertising O Other Advertising (Yard Signs, Buttons, etc.) P Postage S Surveys & Polls Z Preparation & Production of Advertising 7 Day Pre-Primary Statement 7 Day Pre-General Statement 30 Day Post Primary Statement 30 Day Post-General Statement Purpose Codes City Clerk Contact Info Suzanne McNeel 157 N Broadway Blackfoot, ID 83221 [PHONE REDACTED] ext. 1819 [EMAIL REDACTED]