Form 8872
(Rev. October 2014)
Department of the Treasury
Internal Revenue Service
Political Organization
Report of Contributions and Expenditures
Information about Form 8872 and its instructions is available at www.irs.gov/form8872.
Do not enter social security numbers on this form or any attachments to it as they may be made public.
OMB No. 1545-0123
Open to Public
Inspection
A For the period beginning , 20 and ending , 20
B Check applicable boxes: Initial report
Change of address Amended report
Final report
1
Name of organization
Employer identification number
2
Mailing address (P.O. Box or number, street, and room or suite number)
City or town, state or province, country, and ZIP or foreign postal code
3 Email address of organization
4 Date organization was formed
5a
Name of custodian of records
5b Custodian's address
6a
Name of contact person
6b Contact person's address
7
Business address of organization (if different from mailing address shown above). Number, street, and room or suite number
City or town, state or province, country, and ZIP or foreign postal code
8 Type of report (check only one box)
a
First quarterly report (due by April 15)
b
Second quarterly report (due by July 15)
c
Third quarterly report (due by October 15)
d
Year-end report (due by January 31)
e
Mid-year report (Non-election year only–due by July 31)
f
Monthly report for the month of:
(due by the 20th day following the month shown above, except the
December report, which is due by January 31)
g
Pre-election report (due by the 12th or 15th day before the
election)
(1)
Type of election:
(2)
Date of election:
(3)
For the state of:
h
Post-general election report (due by the 30th day after general
election)
(1)
Date of election:
(2)
For the state of:
9 Total amount of reported contributions (total from all attached Schedules A) . . . . . . . . . . . 9
10 Total amount of reported expenditures (total from all attached Schedules B) . . . . . . . . . . . 10
Sign
Here
Under penalties of perjury, I declare that I have examined this report, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete.
Signature of authorized official
Date
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 30406G
Form 8872 (Rev. 10-2014)
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Form 8872 (Rev. 10-2014)
Schedule A
Itemized Contributions
(DO NOT enter social security numbers on this schedule.)
Schedule A page of
Name of organization Employer identification number
Contributor's name, mailing address and ZIP code
Name of contributor's employer
Contributor's occupation
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Contributor's name, mailing address and ZIP code
Name of contributor's employer
Contributor's occupation
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Contributor's name, mailing address and ZIP code
Name of contributor's employer
Contributor's occupation
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Contributor's name, mailing address and ZIP code
Name of contributor's employer
Contributor's occupation
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Contributor's name, mailing address and ZIP code
Contributor's occupation
Name of contributor's employer
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Contributor's name, mailing address and ZIP code
Name of contributor's employer
Contributor's occupation
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Contributor's name, mailing address and ZIP code
Name of contributor's employer
Contributor's occupation
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Contributor's name, mailing address and ZIP code
Name of contributor's employer
Contributor's occupation
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Contributor's name, mailing address and ZIP code
Name of contributor's employer
Contributor's occupation
Aggregate contributions
year-to-date . . . . .
$
Amount of contribution
$
Date of contribution
Subtotal of contributions reported on this page only. Enter here and also include this amount in the total on line 9 of
Form 8872 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Form 8872 (Rev. 10-2014)
Open to Public Inspection
Form 8872 (Rev. 10-2014)
Schedule B
Itemized Expenditures (
DO NOT enter social security numbers on this schedule.)
Schedule B page of
Name of organization Employer identification number
Recipient's name, mailing address and ZIP code
Name of recipient's employer
Recipient's occupation
Amount of expenditure
$
Date of expenditure
Purpose of expenditure
Recipient's name, mailing address and ZIP code
Name of recipient's employer
Recipient's occupation
Amount of expenditure
$
Date of expenditure
Purpose of expenditure
Recipient's name, mailing address and ZIP code
Name of recipient's employer
Recipient's occupation
Amount of expenditure
$
Date of expenditure
Purpose of expenditure
Recipient's name, mailing address and ZIP code
Name of recipient's employer
Recipient's occupation
Amount of expenditure
$
Date of expenditure
Purpose of expenditure
Recipient's name, mailing address and ZIP code
Name of recipient's employer
Recipient's occupation
Amount of expenditure
$
Date of expenditure
Purpose of expenditure
Recipient's name, mailing address and ZIP code
Name of recipient's employer
Recipient's occupation
Amount of expenditure
$
Date of expenditure
Purpose of expenditure
Subtotal of expenditures reported on this page only. Enter here and also include this amount in the total on line 10 of
Form 8872 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Form 8872 (Rev. 10-2014)
Open to Public Inspection
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