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THE STATE OF MONTANA COMMISSIONER OF POLITICAL PRACTICES 1205 Eighth Avenue Post Office Box 202401 Helena, MT 59620-2401 TELEPHONE: [PHONE REDACTED] FAX NUMBER: [PHONE REDACTED] WEBSITE: www.politicalpractices.mt.qov INSTRUCTIONS (Revised 11/11) FORM C-1-A STATEMENT OF CANDIDATE WHO IS REQUIRED TO FILE A FORM C-1 -AJ? • All candidates campaigning for county and municipal offices must file a Form C-1-A. • All candidates campaigning for school trustee offices in first-class districts located in counties with populations of 15,000 and more or in county high school districts having student enrollments of 2,000 or more must file a Form C-1-A. WHAT INFORMATION IS TO BE REPORTED? Pursuant to Montana Code Annotated 13-37-201 , 13-37-202, and 13-37-205, the following information is required to be reported: • full name, complete mailing address, and complete street address of the treasurer; • full name, complete mailing address, and complete street address of any deputy treasurer; and • full name and complete address of the depository in which the campaign account is located. Please note: • A candidate may appoint himself or herself as the campaign treasurer or deputy treasurer. Such an appointment subsequently may be changed by filing an amended Form C-1-A. • The treasurer of a candidate's campaign is responsible for keeping detailed accounts of all contributions received and expenditures made by the campaign. • The treasurer of a candidate's campaign is the individual to whom correspondence and notices will be sent unless the Commissioner's office is otherwise directed. • A separate bank account must be established for a campaign in which any funds, including the candidate's personal funds, will be received or spent, that is, if Box B or C is checked on the Affidavit of Reporting Status on Form C-1-A. In accordance with 44. 10.407 Administrative Rules of Montana, if Box B has been checked and more than $500 subsequently is received and/or expended, an initial financial report (Form C-5) must be filed within five days of exceeding $500 and financial reports must be filed according to schedule. WHEN MUST A FORM C-1-A BE FILED? A Form C-1-A must be filed within five days after receiving or spending money, appointing a campaign treasurer, or filing for office, whichever occurs first. WHERE MUST A FORM C-1 -A BE FILED? • One copy is to be filed with the Commissioner of Political Practices at the address above. The report may be faxed provided the original report is submitted to the Commissioner immediately thereafter. The Commissioner's fax number and mailing address are provided above. • One copy is to be filed with the Election Administrator of the candidate's resident county or, in the case of a school election, with the district clerk. • One copy is to be retained for the candidate's records. Please detach these instructions before filing Form C-1-A ---PAGE BREAK--- THE STATE OF MONTANA FOR OFFICE USE ONLY Date Received and Postmark Date COMMISSIONER OF POLITICAL PRACTICES 1205 Eighth Avenue Post Office Box 202401 Helena, MT 59620-2401 TELEPHONE: [PHONE REDACTED] FAX NUMBER: [PHONE REDACTED] WEBSITE: www.politicalpractices.mt.gov Form C-1-A (Revised 11/11) Statement of Candidate TO BE FILED by CANDIDATE for COUNTY, MUNICIPAL or SCHOOL OFFICE ORIGINAL FILING O AMENDED FILING 0 TYPE OR PRINT IN INK ALL INFORMATION WITH EXCEPTION OF SIGNATURE FULL NAME OF CANDIDATE COMPLETE DESCRIPTION OF OFFICE SOUGHT PARTY AFFILIATION, if any COUNTY OF RESIDENCE COMPLETE MAILING ADDRESS (Including City, State, Zip Code) COMPLETE STREET ADDRESS (Including City, State, Zip Code) E-Mail Address (Please Print) Home Telephone Number Work Telephone Number FULL NAME OF CAMPAIGN TREASURER (Must be registered to vote in Montana) COMPLETE MAILING ADDRESS (Including City, State, Zip Code) COMPLETE STREET ADDRESS (Including City, State, Zip Code) E-Mail Address (Please Print) Home Telephone Number Work Telephone Number FULL NAME OF DEPUTY TREASURER, if any (Must be registered to vote in Montana) COMPLETE MAILING ADDRESS (Including City, State, Zip Code) E-Mail Address (Please Print) Home Telephone Number Work Telephone Number CAMPAIGN ACCOUNT INFORMATION FULL NAME OF BANK COMPLETE ADDRESS (Including City, State, Zip Code) Facsimile Number Facsimile Number Facsimile Number AFFIDAVIT OF REPORTING STATUS (Check one) If B or C box is checked, a treasurer and bank must be designated. AO I certify that I will not receive or expend any funds (including personal funds) in support of my candidacy for above office. so I certify that I expect the total amount of contributions or expenditures will not exceed $500 (including personal funds); however, if more than $500 is received and/or expended, within 5 days of reaching this threshold I will file an initial financial report (form C-5) and I will file additional financial reports according to schedule. cD I expect to receive contributions and/or make expenditures exceeding $500 (including personal funds). I will file financial reports (form C-5) according to schedule. CERTIFICATION: I hereby verify that the foregoing statements are true and correct. Candidate's Signature Date