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Space Below For Office Use Only Colorado Secretary of State Rev. 12/09 STATEMENT OF PERSONAL EXPENDITURES BY A CANDIDATE [1-45-108(1) & 1-45-109, C.R.S.] For use by a candidate who has not received any contributions (does not have a candidate committee), but has made expenditures of personal funds. Name of Candidate: Address of Candidate: City: State: Zip Code: Office: District Reporting Period: Beginning Date Ending Date Total amount of Non-Itemized Expenditures ($19.99 or less): Expenditures exceeding $19.99 shall be itemized and listed below. Date Expended Amount Name of Recipient Address $ City State Zip Comment / Purpose Date Expended Amount Name of Recipient Address $ City State Zip Comment / Purpose Date Expended Amount Name of Recipient Address $ City State Zip Comment / Purpose I certify to the best of my knowledge this Statement of Expenditures is true and correct. 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