Commonwealth of Pennsylvania - Campaign Finance Report (Note: This report must be clear and legible. It should be typed) Filer Identification Number Name of Filing Committee, Candidate or Lobbyist Street Address City Type of Report (Place x under report type) 1- 6th Tuesday 2- 2 nd Friday 3- 30 Day Post 4- 6 th Tuesday 5- 2nd Friday 6- 30 Day Post Pre-Primary Pre-Primary Primary Pre- Election Pre- Election Election 7- Annual Special 2nd Friday Pre-Election Special 30 Day Post-Election Report Filed By ( Mark X) Candidate Committee Lobbyist State Zip Code Date Of Election (MM/DD/YYYY) Summary of Receipts and Expenditures From Date Year To Date Amendment Report Termination Report 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 My Commission expires_________________________ MO. DAY YR. ____________________________________________________ Signature of Person Submitting report ____________________________________________________ Printed Name _____________ 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 My Commission expires_________________________ MO. DAY YR. ____________________________________________________ Signature of Candidate ____________________________________________________ Printed Name _____________ Area Code ___________________________ Daytime Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com 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 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 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 4. Other Receipts-Refunds, Interest Earned, Returned Checks, ETC. (From Part E) Total for the reporting period (4) $ $ (3) $ $ $ (2) $ $ $ (1) $ 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) American LegalNet, Inc. www.FormsWorkFlow.com 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 House # City Full Name of Contributing Committee House # Street Address Street Address State Zip Code Date [MM/DD/YYYY] $ Date [MM/DD/YYYY] $ Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ Date [MM/DD/YYYY] $ City Full Name of Contributing Committee House # Street Address State Zip Code Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ Date [MM/DD/YYYY] $ City Full Name of Contributing Committee House # Street Address State Zip Code Date [MM/DD/YYYY] Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ $ City State Zip Code Date [MM/DD/YYYY] $ Full Name of Contributing Committee House # Street Address State Zip Code Date [MM/DD/YYYY] $ Date [MM/DD/YYYY] $ City Full Name of Contributing Committee House # Street Address Date [MM/DD/YYYY] Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ $ City State Zip Code Date [MM/DD/YYYY] $ American LegalNet, Inc. www.FormsWorkFlow.com 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 # Street Address State Zip Code Date [MM/DD/YYYY] $ City Full Name of Contributor Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ House # Street Address State Zip Code Date [MM/DD/YYYY] $ City Full Name of Contributor Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ House # Street Address State Zip Code Date [MM/DD/YYYY] $ City Date [MM/DD/YYYY] $ Full Name of Contributor House # Street Address Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ City Full Name of Contributor State Zip Code Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ House # Street Address Date [MM/DD/YYYY] $ City Full Name of Contributor State Zip Code Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ House # Street Address State Zip Code Date [MM/DD/YYYY] $ City Date [MM/DD/YYYY] $ American LegalNet, Inc. www.FormsWorkFlow.com 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 House # Street Address State Zip Code Date [MM/DD/YYYY] $ Date [MM/DD/YYYY] $ City Date [MM/DD/YYYY] $ Full Name of Contributing Committee House # Street Address State Zip Code Date [MM/DD/YYYY] $ Date [MM/DD/YYYY] $ City Full Name of Contributing Committee House # Street Address Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ Date [MM/DD/YYYY] $ City Full Name of Contributing Committee House # Street Address State Zip Code Date [MM/DD/YYYY] Date [MM/DD/YYYY] $ $ Date [MM/DD/YYYY] $ City Full Name of Contributing Committee House # Street Add