Fillable Commonwealth of Pennsylvania Campaign Finance Report (Pennsylvania)

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Commonwealth of Pennsylvania Campaign Finance Report (Pennsylvania)

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The Commonwealth of Pennsylvania Campaign Finance Report (Pennsylvania) form is 18 pages long and contains:

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  • 14 check-boxes
  • 641 other fields

Country of origin: US
File type: PDF

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Commonwealth of Pennsylvania
-
Campaign Finance Report
(Note: This report must be clear and legible. It should be typed)
Filer Identification
Number
Report Filed By
( Mark X)
Candidate Committee Lobbyist
Name of Filing Committee, Candidate or
Lobbyist
Street Address
City State
Zip Code
Type of Report (Place x under report type)
1- 6
th
Tuesday
Pre-Primary
6- 30 Day Post
Election
7- Annual Special 2
nd
Friday
Pre-Election
Special 30 Day
Post-Election
Date Of Election
(MM/DD/YYYY)
Year Amendment
Report
Termination
Report
Summary of Receipts and
Expenditures
From Date To Date For Office Use Only
A. Amount Brought Forward From Last Report
$
B. Total Monetary Contributions and Receipts
(From Schedule I)
$
C. Total Funds Available
(Sum of Lines A and B)
$
D. Total Expenditures
(From Schedule III)
$
E. Ending Cash Balance
(Subtract Line D from Line C)
$
F. Value of In-Kind Contributions Received
(From Schedule II)
$
G. Unpaid Debts and Obligations
(From Schedule IV)
$
Affidavit Section
Part 1- If this is a Committee report, treasurer sign here. If this is a Candidate report, candidate sign here.
I swear (or affirm) that this report, including the attached schedules on paper, is to the best of my knowledge and belief true, correct and complete.
Sworn to and subscribed before me this
_________day of__________________20__________ ____________________________________________________
Signature of Person Submitting report
____________________________________________ ____________________________________________________
Signature Printed Name
My Commission expires_________________________ _____________ ___________________________
MO. DAY YR. Area Code Daytime Telephone Number
Part II- If this is a report of a Candidate's Authorized Committee, candidate shall sign here.
I swear (or affirm) that to the best of my knowledge and belief this political committee has not violated any provisions of the Act of June 3, 1937 (P.L. 1333, NO.320) as
amended.
Sworn to and subscribed before me this
_________day of__________________20__________ ____________________________________________________
Signature of Candidate
____________________________________________ ____________________________________________________
Signature Printed Name
My Commission expires_________________________ _____________ ___________________________
MO. DAY YR. Area Code Daytime Telephone Number
Pre-Primary
Friday
nd
2- 2
Primary
3- 30 Day Post
Friday
nd
5- 2
Pre- Election
Pre- Election
Tuesday
4- 6
th
Print Form
Reset Form
click to sign
signature
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SCHEDULE I
Contributions and Receipts
Detailed Summary Page
Filer Identification Number
1.Unitemized Contributions and Receipts-$50.00 or Less per Contributor
Total for the reporting period (1) $
2. Contributions of $50.01 to $250.00 (From
Part A and Part B)
Contributions Received from Political Committees (Part A) $
All Other Contributions (Part B) $
Total for the reporting period (2) $
3. Contributions Over $250.00 (From Part C and Part D)
Contributions Received from Political Committees (Part C) $
All Other Contributions (Part D) $
Total for the reporting period (3) $
4. Other Receipts-Refunds, Interest Earned, Returned Checks, ETC. (From Part E)
Total for the reporting period (4) $
Total Monetary Contributions and Receipts during this reporting period
(Add and
enter amount totals from Boxes 1, 2, 3 and 4; also enter this amount on Page 1, Report
Cover Page, Item B)
$
PART A
Contributions Received From Political Committees
$50.01 TO $250.00
Use this Part to itemize only contributions received from Political Committees
with an aggregate value from $50.01 TO $250.00 in the reporting period.
Filer Identification Number
Amount
Full Name of Contributing
Committee
Date [MM/DD/YYYY]
$
House #
Date [MM/DD/YYYY]
$
City
State Zip Code Date [MM/DD/YYYY]
$
Full Name of Contributing
Committee
Date [MM/DD/YYYY]
$
House # Date [MM/DD/YYYY]
$
City
State
Zip Code Date [MM/DD/YYYY]
$
Full Name of Contributing
Committee
Date [MM/DD/YYYY]
$
House # Date [MM/DD/YYYY]
$
City State
Zip Code
Date [MM/DD/YYYY]
$
Full Name of Contributing
Committee
Date [MM/DD/YYYY]
$
House #
Date [MM/DD/YYYY]
$
City
State
Zip Code
Date [MM/DD/YYYY]
$
Full Name of Contributing
Committee
Date [MM/DD/YYYY]
$
House #
Date [MM/DD/YYYY]
$
City
State
Zip Code
Date [MM/DD/YYYY]
$
Full Name of Contributing
Committee
Date [MM/DD/YYYY]
$
House #
Date [MM/DD/YYYY]
$
City
State
Zip Code
Date [MM/DD/YYYY]
$
Street Address
Street Address
Street Address
Street Address
Street Address
Street Address
PART B
All Other Contributions
$50.01 TO $250
Use this Part to itemize all other contributions with an aggregate value from
$50.01 TO $250 in the reporting period.
(Exclude contributions from political committees reported in Part A.)
Filer Identification Number:
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Street Address
Street Address
Street Address
Street Address
Street Address
Street Address
PART C
Contributions Received From Political Committees
Over $250.00
Use this Part to itemize only contributions received from Political Committees
with an aggregate value over $250.00 in the reporting period.
Filer Identification Number:
Full Name of
Contributing Committee
Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of
Contributing Committee
Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of
Contributing Committee
Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of
Contributing Committee
Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of
Contributing Committee
Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Full Name of
Contributing Committee
Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Street Address
Street Address
Street Address
Street Address
Street Address
Street Address
PART D
All Other Contributions
Over $250.00
Use this Part to itemize all other contributions with an aggregate value over $250.00 in the reporting period.
(Exclude contributions from political committees reported in Part C)
Filer Identification Number:
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address /
Principal Place of Business
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address /
Principal Place of Business
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address /
Principal Place of Business
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address /
Principal Place of Business
Street Address
Street Address
Street Address
Street Address
PART E
Other Receipts
REFUNDS, INTEREST INCOME, RETURNED CHECKS, ETC.
Use this Part to report refunds received, interest earned, returned checks and prior expenditures that were returned to the filer.
Filer Identification Number:
Full Name
House #
City State Zip
Code
Date [MM/DD/YYYY] $
Receipt Description
Full Name
House #
City State Zip
Code
Date [MM/DD/YYYY] $
Receipt Description
Full Name
House #
City State Zip
Code
Date [MM/DD/YYYY] $
Receipt Description
Full Name
House #
City State Zip
Code
Date [MM/DD/YYYY] $
Receipt Description
Full Name
House #
City State Zip
Code
Date [MM/DD/YYYY] $
Receipt Description
Full Name
House #
City State Zip
Code
Date [MM/DD/YYYY] $
Receipt Description
Street Address
Street Address
Street Address
Street Address
Street Address
Street Address
SCHEDULE ll
IN-KIND CONTRIBUTIONS AND VALUABLE THINGS RECEIVED
USE THIS SCHEDULE TO REPORT ALL IN-KIND CONTRIBUTIONS OF VALUABLE THINGS DURING THE REPORTING PERIOD
DETAILED SUMMARY PAGE
Filer Identification Number:
1. UNITEMIZED IN-KIND CONTRIBUTIONS RECEIVED-VALUE OF $50.00 OR LESS PER CONTRIBUTOR
TOTAL for the reporting period (1) $
2. IN-KIND CONTRIBUTIONS RECEIVED-VALUE OF $50.01 TO $250.00 (FROM PART F)
TOTAL for the reporting period (2) $
3. IN-KIND CONTRIBUTION RECEIVED-VALUE OVER $250.00 (FROM PART G)
TOTAL for the reporting period (3) $
TOTAL VALUE OF IN-KIND CONTRIBUTIONS DURING THIS REPORTING
PERIOD (Add and enter amount totals from boxes 1, 2, and 3; also enter
on Page 1, Report Cover Page, Item F)
$
SCHEDULE II
PART F
In-Kind Contributions Received
VALUE OF $50.01 TO $250
Filer Identification Number:
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Description of Contribution
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Description of Contribution
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Description of Contribution
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Description of Contribution
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Description of Contribution
Street Address
Street Address
Street Address
Street Address
Street Address
SCHEDULE II
Part G
In-Kind Contributions Received
VALUE OVER $250
Filer Identification Number:
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address / Principal
Place of Business
Description
of
Contribution
Full Name of Contributor
Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address / Principal
Place of Business
Description
of
Contribution
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address / Principal
Place of Business
Description
of
Contribution
Full Name of Contributor Date [MM/DD/YYYY] $
House # Date [MM/DD/YYYY] $
City State Zip Code Date [MM/DD/YYYY] $
Employer Name Occupation
Employer Mailing Address / Principal
Place of Business
Description
of
Contribution
Street Address
Street Address
Street Address
Street Address
SCHEDULE III
Statement of Expenditures
Filer Identification Number:
To Whom Paid Date [MM/DD/YYYY] $
House # Description of Expenditure
City State Zip
Code
To Whom Paid Date [MM/DD/YYYY] $
House # Description of Expenditure
City State Zip
Code
To Whom Paid Date [MM/DD/YYYY] $
House # Description of Expenditure
City State Zip
Code
To Whom Paid Date [MM/DD/YYYY] $
House # Description of Expenditure
City State Zip
Code
To Whom Paid Date [MM/DD/YYYY] $
House # Description of Expenditure
City State Zip
Code
To Whom Paid Date [MM/DD/YYYY] $
House # Description of Expenditure
City State Zip
Code
To Whom Paid Date [MM/DD/YYYY] $
House # Description of Expenditure
City State Zip
Code
To Whom Paid Date [MM/DD/YYYY] $
House # Description of Expenditure
City State Zip
Code
Street Address
Street Address
Street Address
Street Address
Street Address
Street Address
Street Address
Street Address
SCHEDULE IV
Statement of Unpaid Debts
Use this Section to itemize all unpaid debts and obligations which are outstanding at the end of the reporting period.
Filer Identification Number:
Name of Creditor Outstanding Balance of Debt
House # DATE DEBT INCURRED
[MM/DD/YYYY]
$
City State Zip
Code
Description of Debt
Name of Creditor Outstanding Balance of Debt
House # DATE DEBT INCURRED
[MM/DD/YYYY]
$
City State Zip
Code
Description of Debt
Name of Creditor Outstanding Balance of Debt
House # DATE DEBT INCURRED
[MM/DD/YYYY]
$
City State Zip
Code
Description of Debt
Name of Creditor Outstanding Balance of Debt
House # DATE DEBT INCURRED
[MM/DD/YYYY]
$
City State Zip
Code
Description of Debt
Name of Creditor Outstanding Balance of Debt
House # DATE DEBT INCURRED
[MM/DD/YYYY]
$
City State Zip
Code
Description of Debt
Name of Creditor Outstanding Balance of Debt
House # DATE DEBT INCURRED
[MM/DD/YYYY]
$
City State Zip
Code
Description of Debt
Street Address
Street Address
Street Address
Street Address
Street Address
Street Address
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Commonwealth of Pennsylvania Campaign Finance Report (Pennsylvania)

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Completed 18 May 2021

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