COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF COMMISSIONS, ELECTIONS AND LEGISLATION 210 NORTH OFFICE BUILDING HARRISBURG, PENNSYLVANIA 17120-0029 TELEPHONE (717) 787-5280 FAX (717) 705-0721 POLITICAL CONTRIBUTIONS REQUIRED TO BE REPORTED UNDER §1641 This report must be filed with the Secretary of the Commonwealth on or before February fifteenth of every year. This form is to be used by any corporation, company, association, partnership, sole proprietorship or other business entity, which has been awarded any non-bid contract from the Commonwealth or, any of its political subdivisions during the calendar year immediately preceding the filing date of this report. A business entity shall itemize in this report all political contributions made during the preceding calendar year by: (1) any officer, director, associate, partner, limited partner, individual owner or members of their immediate family when the contributions exceed an aggregate of one thousand dollars ($1,000) by any individual during the preceding year; or (2) any employee or member of his/her immediate family whose political contribution exceeded one thousand dollars ($1,000) during the preceding year; where the making of such contributions are actually known at the time of this report to any officer, director, associate, partner, limited partner or individual owner of the business entity. For the purpose of this report, "immediate family" means a person's spouse and any unemancipated child. Attach additional 8 ½"x 11" pages if more space is needed. I SWEAR (OR AFFIRM) THAT THIS REPORT, INCLUDING ATTACHMENTS, IS A FULL TRUE AND DETAILED ACCOUNT OF EACH AND ALL POLITICAL CONTRIBUTIONS KNOWN TO THE NAMED BUSINESS ENTITY BY VIRTUE OF THE ACTUAL KNOWLEDGE POSSESSED BY ANY OFFICER, DIRECTOR, ASSOCIATE PARTNER, LIMITED PARTNER OR INIVIDUAL OWNER, IN ACCORDANCE WITH THE REQUIREMENTS OF SECTION 1641 OF THE PENNSYLVANIA ELECTION CODE. (25 P.S. § 3260(a)). ______________________________________________ NAME OF BUSINESS ENTITY ______________________________________________ SWORN TO AND SUBSCRIBED BEFORE ME THIS SIGNATURE OF PERSON SUBMITTING REPORT __________ DAY OF _____________________ 20 ____ ______________________________________________ PRINTED NAME ______________________________________________ _____________________________________________ SIGNATURE TITLE MY COMMISSION EXPIRES _______________________ MO. DAY YR. _______________ AREA CODE ____________________________ DAYTIME TELEPHONE NUMBER DSEB-504 (10/03) American LegalNet, Inc. www.FormsWorkFlow.com NAME OF BUSINESS ENTITY _____________________________________________________________ ADDRESS ________________________________________________________________________________ POLITICAL CONTRIBUTIONS REQUIRED TO BE REPORTED Date Contributed Name of Contributor Title or Relationship To Whom Contributed Amount of Contribution American LegalNet, Inc. www.FormsWorkFlow.com