Fillable STATEMENT OF ORGANIZATION (Florida Division of Corporations)

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STATEMENT OF ORGANIZATION (Florida Division of Corporations)

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STATEMENT OF ORGANIZATION
OF POLITICAL COMMITTEE
OFFICE USE ONLY
(PLEASE TYPE)
1. Full Name of Committee
Telephone
Mailing Address (include city, state and zip code)
Street Address (include city, state and zip code)
2. Affiliated or Connected Organizations (includes other committees of continuous existence and political
committees)
Name of Affiliated or
Connected Organization
Mailing Address Relationship
3. Area, Scope and Jurisdiction of the Committee
4. Nature of Organization or Organization’s Special Interest (e.g., medical, legal, education, etc.)
5. Identify by Name, Address and Position, the Custodian of Books and Accounts (include treasurer’s name)
Full Name Mailing Address Committee Title or Position
DS-DE 5 (Rev. 06/11) – Rule 1S-2.017
(continued on reverse side)
6. List by
Name, Address and Position, Other Principal Officers, Including Officers and Members of the
Finance Committee, If Any (include chairman’s name)
Full Name Mailing Address Committee Title or Position
7. List by Name, Address, Office Sought and Party Affiliation Each Candidate or Other Individual that this
Committee is Supporting (if none, please indicate)
Full Name Mailing Address Office Sought Party
8. List Any Issues this Committee is Supporting:
List Any Issues this Committee is Opposing:
9. If this Committee is Supporting the Entire Ticket of a Party, Give Name of Party
10. In the Event of Dissolution, What Disposition will be Made of Residual Funds?
11. List all Banks, Safety Deposit Boxes, or Other Depositories Used for Committee Funds
Name of Bank or Depository & Account Number Mailing Address
12. List all Reports Required to be Filed by this Committee with Federal Officials and the Names, Addresses
and Positions of Such Officials, If Any
Report Title Dates Required to be Filed Name & Position of Official Mailing Address
STATE OF
COUNTY
I,
, certify that the information in this Statement of
Organization is complete, true and correct.
X
Date
DS-DE 5 (Rev. 06/11) – Rule 1S-2.017 page 2
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STATEMENT OF ORGANIZATION (Florida Division of Corporations)

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Completed 30 July 2020

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