Full Text
Colorado Secretary of State Form revised 5/2010 INDEPENDENT EXPENDITURE REPORT (1-45-107.5 C.R.S.) This report must be filed by “any person making an independent expenditure in excess of one thousand dollars in any calendar year” pursuant to section 1-45-107.5(4), C.R.S. Registration as an independent expenditure committee is required prior to filing this report. Please reference section 1-45-107.5, C.R.S. Your Name/Entity Name: Committee Name: As Shown On Committee Registration SOS ID NUMBER (for committees that file with the Secretary of State): Type of Report Regularly Scheduled Filing. Amended Filing. This amends previous report filed on (date) . Submit changes or new information only. Termination Report. (Termination reports must have a monetary balance of zero on page 2, line 10) Reporting Period Covered: Through: Begin Date End Date Reporting Entity Information: Full Name of Parent Corporation, if applicable: Include any acronyms used. All Doing-Business-As Names used in Colorado: Address of Home Office: If reporting entity is a subsidiary entity, list the address of the parent corporation’s home office. Name of Colorado Registered Agent: Must be the same as listed on committee registration Colorado Address for Registered Agent: Names of Candidates Supported or Opposed by Independent Expenditures this Period, and position on each: Authorization (Must be completed by the Registered Agent): I hereby certify and declare, under penalty of perjury, that to the best of my knowledge or belief all donations received during this reporting period, including any donations received in the form of membership dues transferred by a membership organization, are from permissible sources. Print Registered Agent’s Name: Registered Agent’s Signature: Date: * Please notify persons who donate $1,000 or more for independent expenditures to this committee in a calendar year that such donors are required to file donor reports pursuant to section 1-45-107.5(9)(a), C.R.S. 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 Space Below For Office Use Only ---PAGE BREAK--- Committee Name: 2 Colorado Secretary of State Form Rev. 05/2010 Reporting Period Overview Beginning Balance this Period (Committees): 1 Total Donations this Period: 2 Monetary: Non-Monetary: Itemized: Non-Itemized: Other Receipts (dividends, interest, etc.): 3 Total Independent Expenditures this Period: 4 Monetary: Non-Monetary: Itemized: Non-Itemized: Total Other Expenditures this Period: 5 Monetary: Non-Monetary: Itemized: Non-Itemized: Loans received this period: 6 Loans paid this period: 7 Returned Independent Expenditures this Period: 8 Returned Donations this Period: 9 Ending Balance (include monetary expenditures and donations only): 10 ---PAGE BREAK--- Committee Name: 3 Colorado Secretary of State Form Rev. 05/2010 Schedule A: Donations 11 Itemized Donations 1. Date Accepted 4. Name: 5. Address (Home Office): 6. City/State/Zip: 7. Monetary Non-Monetary, include Description: 8. Employer (required if applicable): 9. Occupation (required if applicable): 10. Parent Corporation and acronyms used (required if applicable): 11. All DBA Names used in Colorado (required if applicable): 12. Donor’s Colorado Agent Name & Address (required if applicable): 2. Donation Amt. $ 3. Aggregate Amt. $ Please reference section 1-45-107.5 for donation reporting requirements. 1. Date Accepted 4. Name: 5. Address (Home Office): 6. City/State/Zip: 7. Monetary Non-Monetary, include Description: 8. Employer (required if applicable): 9. Occupation (required if applicable): 10. Parent Corporation and acronyms used (required if applicable): 11. All DBA Names used in Colorado (required if applicable): 12. Donor’s Colorado Agent Name & Address (required if applicable): 2. Donation Amt. $ 3. Aggregate Amt. $ Please reference section 1-45-107.5 for donation reporting requirements. 1. Date Accepted 4. Name: 5. Address (Home Office): 6. City/State/Zip: 7. Monetary Non-Monetary, include Description: 8. Employer (required if applicable): 9. Occupation (required if applicable): 10. Parent Corporation and acronyms used (required if applicable): 11. All DBA Names used in Colorado (required if applicable): 12. Donor’s Colorado Agent Name & Address (required if applicable): 2. Donation Amt. $ 3. Aggregate Amt. $ Please reference section 1-45-107.5 for donation reporting requirements. ---PAGE BREAK--- Committee Name: 4 Colorado Secretary of State Form Rev. 05/2010 Non-Itemized Donations Other Receipts (dividends, interest, etc.) 1. Date Accepted 4. Name: 5. Address (Home Office): 6. City/State/Zip: 7. Monetary Non-Monetary, include Description: 8. Employer (required if applicable): 9. Occupation (required if applicable): 10. Parent Corporation and acronyms used (required if applicable): 11. All DBA Names used in Colorado (required if applicable): 12. Donor’s Colorado Agent Name & Address (required if applicable): 2. Donation Amt. $ 3. Aggregate Amt. $ Please reference section 1-45-107.5 for donation reporting requirements. 1. Date Accepted 4. Name: 5. Address (Home Office): 6. City/State/Zip: 7. Monetary Non-Monetary, include Description: 8. Employer (required if applicable): 9. Occupation (required if applicable): 10. Parent Corporation and acronyms used (required if applicable): 11. All DBA Names used in Colorado (required if applicable): 12. Donor’s Colorado Agent Name & Address (required if applicable): 2. Donation Amt. $ 3. Aggregate Amt. $ Please reference section 1-45-107.5 for donation reporting requirements. 1. Total number of non- itemized donations: 2. Total amount of non-itemized donations: $ 1. Total number of other receipts: 2. Total amount of other receipts: $ ---PAGE BREAK--- Committee Name: 5 Colorado Secretary of State Form Rev. 05/2010 Schedule B: Independent Expenditures 12 Itemized Independent Expenditures 1. Date Funds Obligated 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Name(s) of candidate(s) referenced: 8. Communication is broadcast non-broadcast. Medium: 9. This is an electioneering communication (see Art. XXVIII, Sec. 6) . If box is checked, you must also file an electronic electioneering communication report in TRACER. 2. Expenditure Amt. $ Check if amt. is an estimate: Please reference section 1-45-107.5, C.R.S., for independent expenditure reporting requirements. 1. Date Funds Obligated 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Name(s) of candidate(s) referenced: 8. Communication is broadcast non-broadcast. Medium: 9. This is an electioneering communication (see Art. XXVIII, Sec. 6) . If box is checked, you must also file an electronic electioneering communication report in TRACER. 2. Expenditure Amt. $ Check if amt. is an estimate: Please reference section 1-45-107.5, C.R.S., for independent expenditure reporting requirements. 1. Date Funds Obligated 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Name(s) of candidate(s) referenced: 8. Communication is broadcast non-broadcast. Medium: 9. This is an electioneering communication (see Art. XXVIII, Sec. 6) . If box is checked, you must also file an electronic electioneering communication report in TRACER. 2. Expenditure Amt. $ Check if amt. is an estimate: Please reference section 1-45-107.5, C.R.S., for independent expenditure reporting requirements. ---PAGE BREAK--- Committee Name: 6 Colorado Secretary of State Form Rev. 05/2010 Non-Itemized Independent Expenditures 1. Date Funds Obligated 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Name(s) of candidate(s) referenced: 8. Communication is broadcast non-broadcast. Medium: 9. This is an electioneering communication (see Art. XXVIII, Sec. 6) . If box is checked, you must also file an electronic electioneering communication report in TRACER. 2. Expenditure Amt. $ Check if amt. is an estimate: Please reference section 1-45-107.5, C.R.S., for independent expenditure reporting requirements. 1. Date Funds Obligated 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Name(s) of candidate(s) referenced: 8. Communication is broadcast non-broadcast. Medium: 9. This is an electioneering communication (see Art. XXVIII, Sec. 6) . If box is checked, you must also file an electronic electioneering communication report in TRACER. 2. Expenditure Amt. $ Check if amt. is an estimate: Please reference section 1-45-107.5, C.R.S., for independent expenditure reporting requirements. 1. Date Funds Obligated 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Name(s) of candidate(s) referenced: 8. Communication is broadcast non-broadcast. Medium: 9. This is an electioneering communication (see Art. XXVIII, Sec. 6) . If box is checked, you must also file an electronic electioneering communication report in TRACER. 2. Expenditure Amt. $ Check if amt. is an estimate: Please reference section 1-45-107.5, C.R.S., for independent expenditure reporting requirements. 1. Total number of non- itemized expenditures: 2. Total amount of non-itemized expenditures: $ ---PAGE BREAK--- Committee Name: 7 Colorado Secretary of State Form Rev. 05/2010 Schedule C: Other Expenditures (non-independent expenditures) 13 Non-Itemized Expenditures (other than independent expenditures) 1. Date of Expenditure 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Purpose of expenditure: 2. Expenditure Amt. $ Check if amt. is an estimate: 1. Date of Expenditure 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Purpose of expenditure: 2. Expenditure Amt. $ Check if amt. is an estimate: 1. Date of Expenditure 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Purpose of expenditure: 2. Expenditure Amt. $ Check if amt. is an estimate: 1. Date of Expenditure 3. Name of Recipient/Payee: 4. Address: 5. City/State/Zip: 6. Monetary Non-Monetary, include Description: 7. Purpose of expenditure: 2. Expenditure Amt. $ Check if amt. is an estimate: 1. Total number of non- itemized expenditures: 2. Total amount of non-itemized expenditures: $ ---PAGE BREAK--- Committee Name: 8 Colorado Secretary of State Form Rev. 05/2010 Schedule D: Loans 14 Loans Received Loan Payments 1. Date of Loan 4. Loan Source 5. Address: 6. City/State/Zip: 7. Endorsers/Guarantors. List names, addresses, and amount guaranteed: 2. Loan Amount $ 3. Interest Rate 1. Date of Loan 4. Loan Source 5. Address: 6. City/State/Zip: 7. Endorsers/Guarantors. List names, addresses, and amount guaranteed: 2. Loan Amount $ 3. Interest Rate 1. Date of Payment 3. Loan Source 4. Address, City/State/Zip: 5. Original Loan Amount: 6. Balance: 7. Interest Rate: 2. Payment Amount Principal: Interest: 1. Date of Payment 3. Loan Source 4. Address, City/State/Zip: 5. Original Loan Amount: 6. Balance: 7. Interest Rate: 2. Payment Amount Principal: Interest: ---PAGE BREAK--- Committee Name: 9 Colorado Secretary of State Form Rev. 05/2010 Schedule E: Returned Donations and Expenditures 15 Returned Donations (previously reported on Schedule A) Returned Independent Expenditures (previously reported on Schedule B) 16 1. Date Accepted 4. Name: 5. Address: 6. City/State/Zip: 7. Comment: 2. Date Returned 3. Amount $ 1. Date Accepted 4. Name: 5. Address: 6. City/State/Zip: 7. Comment: 2. Date Returned 3. Amount $ 1. Date of Expenditure 4. Name: 5. Address: 6. City/State/Zip: 7. Comment: 2. Date Returned 3. Amount $ 1. Date of Expenditure 4. Name: 5. Address: 6. City/State/Zip: 7. Comment: 2. Date Returned 3. Amount $