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(Type or print clearly) See instructions at bottom of page Name and Address of Nonbusiness Entity Name Address City State Zip I I I I Name and Address of Principal Offi cer or Directors Name Address City State Zip I I I I I I I I I I I I List the name and address of each person whose fees, dues, payments or other consideration paid to the nonbusiness entity during either of the prior two calendar years has exceeded $500; or who is obligated to or has agreed to pay fees, dues, payments or other consideration exceeding $500 to such entity during the current year. Name Address City State Zip I I I I I I I I I I I I I I INSTRUCTIONS Who should fi le this form? Any nonbusiness entity, domiciled in the State of Idaho, which makes expenditures in an amount exceeding one thousand dollars ($1,000) in any calendar year for the purpose of supporting or opposing one or more candidates or measures. (Please note the defi nition of nonbusiness entity and Section 67-6606, Idaho Code - reverse side.) Filing Deadline: This statement shall be fi led within thirty (30) days of exceeding the one thousand dollars ($1,000) threshold. To Be Filed With: Lawerence Denney, Secretary of State PO Box 83720 Boise ID 83720-0080 (208) 334-2852 Fax: (208) 334-2282 Certifi cation: I hereby certify that the information contained herein is a true, complete, and correct statement in accordance with Section 67-6624, Idaho Code. Signature Title Date STATEMENT BY A NONBUSINESS ENTITY C-6 Rev. 1/15 City Clerk Contact Info Suzanne McNeel 157 N Broadway Blackfoot, ID 83221 [PHONE REDACTED] ext. 1819 [EMAIL REDACTED]