COMMONWEALTH OF PENNSYLVANIA POLITICAL COMMITTEE REGISTRATION STATEMENT THIS REGISTRATION STATEMENT IS BEING FILED ON BEHALF OF NAME OF COMMITTEE OR LOBBYIST COMMITTEE CONTRIBUTING LOBBYIST DATE ________________ CHECK BELOW: ADDRESS INITIAL REGISTRATION AMENDED REGISTRATION CITY STATE ZIP-PLUS FOUR IF THIS IS AN AMENDMENT: FILER ID NUMBER ________________ CHECK ALL THAT APPLY: COUNTY DAYTIME TELEPHONE NUMBER: AREA ____/_______________________ E-MAIL ADDRESS: NEW COMMITTEE ADDRESS NEW CHAIRPERSON NEW TREASURER ___________________________________________ YES NO IS THIS A CANDIDATE'S AUTHORIZED POLITICAL COMMITTEE? OTHER ________________ (SPECIFY) SUPPORTED CANDIDATES List below the names of candidates the committee/lobbyist intends to support, or candidates who have authorized the committee to receive funds on their behalf. A committee that is not a candidate's authorized political committee may list the offices of candidates it intends to support (e.g., Statewide, Legislative, Judicial, Local, All) and need not list names of specific candidates. Name of Candidate(s) Address Office Sought Political Party/Body IF THE COMMITTEE INTENDS TO SUPPORT OR OPPOSE A BALLOT QUESTION, PLEASE COMPLETE THIS SECTION. THIS COMMITTEE SUPPORTS OPPOSES THE FOLLOWING BALLOT QUESTION: FOR OFFICE USE ONLY HOW LONG DOES THE COMMITTEE (OR LOBBYIST) INTEND TO OPERATE: ELECTION YEAR _____________ONLY INDEFINITELY Department of State DSEB-500 (12-99)W · Bureau of Commissions, Elections and Legislation 210 North Office Building · Harrisburg, PA 17120-0029 · (717) 787-5280 American LegalNet, Inc. www.FormsWorkFlow.com AFFILIATED AND CONNECTED ORGANIZATIONS Affiliated means (1) authorized committees of the same candidate, and (2) committees, including separate segregated funds, established, administered, maintained or controlled by the same corporation, unincorporated association, person or group of persons, including a parent, subsidiary, branch, division, dept. or local unit. Connected means an organization which is not a political committee but which directly or indirectly establishes, maintains, controls or administers the registrant, such as a corporation, an unincorporated association, a membership organization, a cooperative or a trade association. NAME OF AFFILIATED/CONNECTED ORGANIZATIONS MAILING ADDRESS AND ZIP CODE RELATIONSHIP TO REGISTRANT APPOINTMENT AND ACCEPTANCE OF CHAIRPERSON FULL NAME OF CHAIRPERSON MAILING ADDRESS AND ZIP CODE DAYTIME TELEPHONE NUMBER AREA _________ NUMBER ___________________________________________ I accept the appointment of chairperson of this committee until the final campaign finance report is filed, or until my successor is duly chosen and the appropriate supervisor is notified. I understand the campaign finance reporting law requirements. I also understand that if I wish to resign, I must do so in writing to the committee. __________________________________________________________ SIGNATURE OF CHAIRPERSON ___________________________ DATE APPOINTMENT AND ACCEPTANCE OF TREASURER FULL NAME OF TREASURER MAILING ADDRESS AND ZIP CODE DAYTIME TELEPHONE NUMBER AREA _________ NUMBER ___________________________________________ I accept the appointment of treasurer of this committee until the final campaign finance report is filed, or until my successor is duly chosen and the appropriate supervisor is notified. I understand the campaign finance reporting law requirements. I also understand that if I wish to resign, I must do so in writing to the committee. __________________________________________________________ SIGNATURE OF TREASURER ___________________________ DATE LIST BELOW NAMES OF BANKS, SAFETY DEPOSIT BOXES OR OTHER FINANCIAL REPOSITORIES NAME OF BANKS, REPOSITORIES, ETC. MAILING ADDRESS PRINTED NAME OF PERSON SUBMITTING THIS STATEMENT SIGNATURE OF PERSON SUBMITTING THIS STATEMENT DATE American LegalNet, Inc. www.FormsWorkFlow.com