Fillable OAK071359 Reimbursement Claim Form (LPF Claim Form No 3)

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OAK071359 Reimbursement Claim Form (LPF Claim Form No 3)

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LPF Form No. 3
Cover Sheet
Public Ethics Commission
1
Candidate Name: __________________________________________
Itemization of Claim Information for LPF Form 3
Item
#
Date of
Expenditure
Campaign
Check #
Payee
Expenditure
Category
1
Expenditure
Amount
PEC
Approved
(For Staff use)
1
2
3
4
5
6
7
8
9
10
Total
Staff Use Only
Total invoices submitted for reimbursement:
Maximum LPF amount for each certified candidate:
Total invoices paid as of present date:
Balance until maximum LPF amount is met:
Total claim amount approved for reimbursement:
1
Allowable expenditure categories include the following:
1) Candidate filing or ballot fee
2) Printed campaign literature and production costs
3) Postage
4) Print advertisements
5) Radio airtime and production costs
6) Television or cable airtime and production costs
7) Website design and maintenance costs
$ 0.00
RESET FORM
Public Ethics Commission Limited Public Financing Program - 2018 Election
17
LPF FORM 3 Reimbursement Claim Form
Please type or print clearly in ink.
I. CANDIDATE INFORMATION
Name:
District Office Sought:
Date of Election:
II. ATTACHMENTS
Each candidate must submit with this claim form the following:
Copies of billing invoices for which reimbursement is sought
Copies of the check(s) used to pay the invoices for which reimbursement is sought
Copies of any applicable campaign literature, advertisement, radio or television script, or website
configuration
Note: Any claim form that is not accompanied by the above documents will not be considered for payment.
The attached copies document a claim for reimbursement for the following permitted categories of
expenditures:
☐
Candidate filing or ballot fees
☐
Printed campaign literature and production costs
☐Postage ☐Print advertisements
☐Radio airtime and production costs ☐Television or cable airtime and production costs
☐
Website design and maintenance costs
III. CANDIDATE AND TREASURER VERIFICATION
I declare under penalty of perjury under the laws of the State of California that to the best of my knowledge:
(1) the information contained in this form and in all attachments submitted herewith are true and correct; (2)
the check(s) used to make payment on the billing invoice(s) submitted for reimbursement represent payment
in full of said invoice(s) and that sufficient funds exist in the candidate's campaign account to provide payment
on those invoices; and (3) any public financing received from the Public Ethics Commission has not been
previously earmarked or specifically encumbered to pay or to secure payment of any loan, return of
contribution, or of any expenditure other than the one for which reimbursement was sought.
Executed on __________________________ at___________________________________________
____________________________________ _____________________________________
Candidate Name Candidate Signature
Public Ethics Commission Limited Public Financing Program - 2018 Election
Executed on ________________________ at ___________________________________________
___________________________________ ______________________________________
Treasurer Name Treasurer Signature
Name(s) of Persons Authorized to Pick up Reimbursement Checks: _________________________________
________________________________________________________________________________________
FOR PEC USE ONLY
Reimbursement Totals
This Period _______________________
Prior Period _______________________
Total Reimbursement: ______________________
Claim Number: ____________________
Check request date: _________________
Check Amount: $_____________________
Authorized by:________________________
This form must be submitted to the Public Ethics Commission at:
Oakland Public Ethics Commission
One Frank H. Ogawa Plaza (City Hall), Room 104
Oakland, CA 94612
(510) 238-3593
(510) 238-3315 (fax)
www.oaklandnet.com/pec
ethicscommission@oaklandnet.com
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OAK071359 Reimbursement Claim Form (LPF Claim Form No 3)

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Completed 7 March 2020

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