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Space Below For Office Use Only Colorado Secretary of State Rev. 12/09 CANDIDATE STATEMENT OF NON-RECEIPT OF CONTRIBUTIONS AND NON-EXPENDITURE OF FUNDS [1-45-108(1) & 1-45-109, C.R.S.] This form is for the use of candidates that do not have a campaign committee and have not received contributions nor made expenditures. No expenditures have been made on behalf of the candidate. Name of Candidate: Address of Candidate: City, State, Zip: Reporting Period: Beginning Date Ending Date CONTRIBUTIONS RECEIVED OR RECEIVABLE DURING THIS REPORTING PERIOD $ 0.00 EXPENDITURES MADE OR INCURRED DURING THIS REPORTING PERIOD $ 0.00 I, affirm that no person received contributions on my behalf nor made any expenditures on my behalf. No contributions have been pledged to me nor on my behalf. I have not received any contributions nor have I made or incurred any expenditures on my own behalf during this election reporting period. Candidate Signature: Date: Colorado Secretary of State Elections Division 1700 Broadway, Ste. 200 Denver, CO 80290 Ph: (303) 894-2200 ext. 6383 Fax: (303) 869-4861 Email: [EMAIL REDACTED] www.sos.state.co.us