8872 Political Organization Report of Contributions and Expen

Form

8872

Political Organization
Report of Contributions and Expenditures

(Rev. October 2014)
Department of the Treasury
Internal Revenue Service

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OMB No. 1545-0123

Open to Public
Inspection

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.

A

For the period beginning

B
1

Check applicable boxes:
Name of organization

2

Mailing address (P.O. Box or number, street, and room or suite number)

, 20
Initial report

and ending

Change of address

, 20

Amended report
Final report
Employer identification number

City or town, state or province, country, and ZIP or foreign postal code
4 Date organization was formed

3

Email address of organization

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)
(3)

h

Date of election:
For the state of:

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)

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9

10

Total amount of reported expenditures (total from all attached Schedules B)

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10

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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

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 30406G

Date
Form

8872 (Rev. 10-2014)

Form 8872 (Rev. 10-2014)

Schedule A

Itemized Contributions (DO NOT enter social security numbers on this schedule.)

Name of organization
Contributor's name, mailing address and ZIP code

Schedule A page
of
Employer identification number

Name of contributor's employer

Amount of contribution

Contributor's occupation

Contributor's name, mailing address and ZIP code

Aggregate contributions
▶
year-to-date . . . . .
Name of contributor's employer

$
Date of contribution
$
Amount of contribution

Contributor's occupation

Contributor's name, mailing address and ZIP code

Aggregate contributions
▶
year-to-date . . . . .
Name of contributor's employer

$
Date of contribution
$
Amount of contribution

Contributor's occupation

Contributor's name, mailing address and ZIP code

Aggregate contributions
▶
year-to-date . . . . .
Name of contributor's employer

$
Date of contribution
$
Amount of contribution

Contributor's occupation

Contributor's name, mailing address and ZIP code

Aggregate contributions
▶
year-to-date . . . . .
Name of contributor's employer

$
Date of contribution
$
Amount of contribution

Contributor's occupation

Contributor's name, mailing address and ZIP code

Aggregate contributions
▶
year-to-date . . . . .
Name of contributor's employer

$
Date of contribution
$
Amount of contribution

Contributor's occupation

Contributor's name, mailing address and ZIP code

Aggregate contributions
▶
year-to-date . . . . .
Name of contributor's employer

$
Date of contribution
$
Amount of contribution

Contributor's occupation

Contributor's name, mailing address and ZIP code

Aggregate contributions
▶
year-to-date . . . . .
Name of contributor's employer

$
Date of contribution
$
Amount of contribution

Contributor's occupation

Contributor's name, mailing address and ZIP code

Aggregate contributions
▶
year-to-date . . . . .
Name of contributor's employer

$
Date of contribution
$
Amount of contribution

Contributor's occupation
Aggregate contributions
year-to-date . . . . .

$
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Open to Public Inspection

▶

$
Form 8872 (Rev. 10-2014)

Form 8872 (Rev. 10-2014)

Schedule B

Itemized Expenditures (DO NOT enter social security numbers on this schedule.)

Name of organization
Recipient's name, mailing address and ZIP code

Schedule B page
of
Employer identification number

Name of recipient's employer

Amount of expenditure

Recipient's occupation

$
Date of expenditure

Name of recipient's employer

Amount of expenditure

Recipient's occupation

$
Date of expenditure

Name of recipient's employer

Amount of expenditure

Recipient's occupation

$
Date of expenditure

Name of recipient's employer

Amount of expenditure

Recipient's occupation

$
Date of expenditure

Name of recipient's employer

Amount of expenditure

Recipient's occupation

$
Date of expenditure

Name of recipient's employer

Amount of expenditure

Recipient's occupation

$
Date of expenditure

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Purpose of expenditure

Recipient's name, mailing address and ZIP code

Purpose of expenditure

Recipient's name, mailing address and ZIP code

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Open to Public Inspection

▶

$
Form 8872 (Rev. 10-2014)