Fillable FORM 1: STATEMENT OF ORGANIZATION FEC 12FE4M5 1. (Federal Election Commission)

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FORM 1: STATEMENT OF ORGANIZATION FEC 12FE4M5 1. (Federal Election Commission)

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FEC
FORM 1
1. NAME OF
COMMITTEE (in full)
ADDRESS (number and street)
FEC FORM 1
(Revised 06/2012)
Office
Use
Only
NOTE: Submission of false, erroneous, or incomplete information may subject the person signing this Statement to the penalties of 52 U.S.C. §30109.
ANY CHANGE IN INFORMATION SHOULD BE REPORTED WITHIN 10 DAYS.
I certify that I have examined this Statement and to the best of my knowledge and belief it is true, correct and complete.
Type or Print Name of Treasurer
Signature of Treasurer Date
4. IS THIS STATEMENT NEW (N) OR AMENDED (A)
STATEMENT OF
ORGANIZATION
▼▼▼
Office Use Only
Example: If typing, type
over the lines.
(Check if name
is changed)
For further information contact:
Federal Election Commission
Toll Free 800-424-9530
Local 202-694-1100
COMMITTEE'S E-MAIL ADDRESS
COMMITTEE'S WEB PAGE ADDRESS (URL)
3. FEC IDENTIFICATION NUMBER
▼
C
12FE4M5
M M / D D / Y Y Y Y
2. DATE
M M / D D / Y Y Y Y
CITY STATE ZIP CODE
▼
(Check if address
is changed)
▼
(Check if address
is changed)
▼
(Check if address
is changed)
Optional Second E-Mail Address
FEC Form 1 (Revised 02/2009) Page 2
5. TYPE OF COMMITTEE
(a) This committee is a principal campaign committee. (Complete the candidate information below.)
(b) This committee is an authorized committee, and is NOT a principal campaign committee. (Complete the candidate
information below.)
(c) This committee supports/opposes only one candidate, and is NOT an authorized committee.
,citarcomeD(etatS ,lanoitaN(
.ytraP ).cte ,nacilbupeReht fo eettimmoc )etanidrobus roa si eettimmoc sihT)d(
(e) This committee is a separate segregated fund. (Identify connected organization on line 6.) Its connected organization is a:
(f) This committee supports/opposes more than one Federal candidate, and is NOT a separate segregated fund or party
committee. (i.e., nonconnected committee)
Name of
Candidate
Name of
Candidate
Candidate
Party Affiliation
State
District
Office
Sought:
House Senate President
In addition, this committee is a Lobbyist/Registrant PAC.
In addition, this committee is a Lobbyist/Registrant PAC.
In addition, this committee is a Leadership PAC. (Identify sponsor on line 6.)
noitazinagrO robaLkcotS latipaC o/w noitaroproCnoitaroproC
evitarepooCnoitaicossA edarTnoitazinagrO pihsrebmeM
Candidate Committee:
Party Committee:
Political Action Committee (PAC):
Joint Fundraising Representative:
(g) This committee collects contributions, pays fundraising expenses and disburses net proceeds for two or more political
committees/organizations, at least one of which is an authorized committee of a federal candidate.
Committees Participating in Joint Fundraiser
1.
2.
3.
4.
(h) This committee collects contributions, pays fundraising expenses and disburses net proceeds for two or more political
committees/organizations, none of which is an authorized committee of a federal candidate.
C
FEC ID number
C
FEC ID number
C
FEC ID number
C
FEC ID number
FEC Form 1 (Revised 02/2009) Page 3
Write or Type Committee Name
8. Treasurer: List the name and address (phone number -- optional) of the treasurer of the committee; and the name and address of
any designated agent (e.g., assistant treasurer).
EDOC PIZETATSYTIC
Full Name
of Treasurer
Mailing Address
Title or Position
Telephone number
6. Name of Any Connected Organization, Affiliated Committee, Joint Fundraising Representative, or Leadership PAC Sponsor
Mailing Address
Relationship: Connected Organization Affiliated Committee Joint Fundraising Representative
EDOC PIZETATSYTIC
Custodian of Records: Identify by name, address (phone number -- optional) and position of the person in possession of committee
books and records.
EDOC PIZETATSYTIC
Full Name
Mailing Address
Title or Position
Telephone number
7.
Leadership PAC Sponsor
9. Banks or Other Depositories: List all banks or other depositories in which the committee deposits funds, holds accounts, rents
safety deposit boxes or maintains funds.
EDOC PIZETATSYTIC
Name of Bank, Depository, etc.
Mailing Address
EDOC PIZETATSYTIC
Name of Bank, Depository, etc.
Mailing Address
FEC Form 1 (Revised 02/2009) Page 4
EDOC PIZETATSYTIC
Full Name of
Designated
Agent
Mailing Address
Title or Position
Telephone number
9. Banks or Other Depositories: List all banks or other depositories in which the committee deposits funds, holds accounts, rents
safety deposit boxes or maintains funds.
▼
▼
▼
▼
▼
▼
CITY STATE ZIP CODE
CITY STATE ZIP CODE
Name of Bank,
Depository, etc.
Mailing Address
FEC Form 1S (Revised 02/2017) Page ___ of ___
8. Designated Agent: Identify by name, address (phone number – optional)
Full Name
Mailing Address
Telephone Number
▼
6. Name of Any Connected Organization, Affiliated Committee, Joint Fundraising Representative, or Leadership PAC Sponsor
▼▼▼
CITY STATE ZIP CODE
Mailing Address
Relationship:
Connected Organization Affiliated Committee Joint Fundraising Representative Leadership PAC Sponsor
1.
FEC ID number
2.
FEC ID number
3.
FEC ID number
4.
FEC ID number
C
C
C
C
TITLE OR POSITION
Optional Supplemental Information
for Lines 5(g) or (h), 6, 8 and/or 9
5(g) or (h). Joint Fundraising Participant:
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FORM 1: STATEMENT OF ORGANIZATION FEC 12FE4M5 1. (Federal Election Commission)

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Completed 26 January 2021

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