I SWEAR (OR AFFIRM) THAT THIS REPORT, INCLUDING ATTACHMENTS, ARE TO THE BEST OF MY KNOWLEDGE AND BELIEF TRUE, CORRECT AND COMPLETE. SWORN TO AND SUBSCRIBED BEFORE ME THIS DAY OF 20 SIGNATURE OF PERSON SUBMITTING REPORT SIGNATURE PRINTED NAME COMMONWEALTH OF PENNSYLVANIA INDEPENDENT EXPENDITURE REPORT FULL NAME OF PERSON FILING NAME OF ORGANIZATION IF FILED ON ONE S BEHALF ADDRESS ( NUMBER AND STREET ) DATE OF PRIMARY OR ELECTION CITY STATE ZIP CODE DAYTIME TELEPHONE E - MAIL ADDRESS TYPE OF REPORT ( CHECK APPROPRIATE BLOCK ) 6 TH TUESDAY PRE - PRIMARY 2 ND FRIDAY PRE - PRIMARY 30 DAY POST - PRIMARY AMENDED REPORT 6 TH TUESDAY PRE - ELECTION 2 ND FRIDAY PRE - ELECTION 30 DAY POST - ELECTION ANNUAL REPORT S UMMARY OF I NDEPENDENT E XPENDITURES P AID T O F ULL N AME AND M AILING A DDRESS P URPOSE ( DESCRIPTION OF EXPENDITURE ) D ATE AMOUNT IF ADDITIONAL SPACE IS NECESSARY TO REPORT EXPENDITURES , PLEA SE ATTACH AN X SHEET OF PAPER TO THIS FORM . MY COMMISSIONS EXPIRES MO . DAY YR . AREA CODE DAYTIME TELEPHONE NUMBER DSEB - 505 ( 04/10 ) D EPARTMENT OF STATE. B UREAU OF C OMMISSIONS , ELECTIONS AND L EGISLATION 210 N ORTH O FFICE B UILDING . H ARRISBURG , P ENNSYLVANIA 17120 - 0029 . (717) 787 - 5280 N AME OF C ANDIDATE OR Q UESTION S UPPORTED O PPOSED American LegalNet, Inc. www.FormsWorkFlow.com INDEPENDENT EXPENDITURE ure by a person made for the purpose of influencing an election without cooperation or consultation with any candidate or any pol it ical committee authorized by the candidate and which is not made in concert with or at the request or suggestion of any candidate or political The Law further provides for reporting independent expenditures at Section 1626 (g) , (25 P.S. 2473246(g)). ion or defeat of a clearly identified candidate, or question appearing on the ballot, other than by a contri bution of a political committee or candidate, in an aggregate amount in excess of one hundred dollars ($100) during a calendar year shall file with the appropri ate supervisor, on a form designed by the Secretary of the Commonwealth, a report which shall in clude the same information required of a candidate or political committee receiving such a contribution and, additionally, the name of the candidate or question suppo rted or opposed. Reports required by this section shall be filed on dates on which report s by political committees making expenditures are required to report under this INSTRUCTIONS FOR FILING INDEPENDENT EXPENDITURE REPORT Persons may make independent expenditures to influence the election of a candidate or ballot question. You must name the candidate or ballot question supported or opposed by the independent expenditure. The filer mu st ex ecute the affidavit in the presence of a notary public . Filers must file this report if the independent expenditure amount, in the aggregate, exceeds $100 in a calendar year. Filers may also use this from for 24 - Hour Expenditure Reporting. The b ureau will accept the filing of late independent expenditure s b y facsimile at 717 - 705 - 0721 , or via email at ra - st campaignfinance@pa.gov When the amount of an independent expenditure exceeds $100, file the report on the next filing deadline. Fil ing deadlines are avai lable on our websi te www.dos. pa.gov ( or at this qu ick link ) . You may also contact the Bureau of E lections at 717 - 787 - 5280 (option 3) or via e - mail at ra - st campaignfinance@pa.gov . Late Filing Penalty In accordance with Section 1632 of the Law (25 P.S. 247 3252), the bureau may assess a penalty of $10.00 for each day or part o f the day (excluding weekends and holidays) that the report is overdue, plus an additional fee of $10.00 for each of the first six days that a report is overdue. Postmarks are acceptable as proof of timely filing where the report is sent by first class mail and postmarked by the U. S. Postal Service not later than the day prior to the filing deadline. Please consult the stat ement on Citiz en s Un ited found on our website www.dos. pa.gov for further information . (07/18) American LegalNet, Inc. www.FormsWorkFlow.com