FTC I,iA'L CEIITER

RECEI VEO

20llJUL

-5

AH 8: t+3

STATEMENT OF ORGANIZATION
1.
NAME OF COMMITTEE (in full) (Check

il name

is changed)

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ZIP CODE

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COMMITTEE

S E-MAIL ADDRESS (Please provide only one e-mait address)

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(check il address is changed)

COMMTTTEPS WEB PAGE ADDRESS (URL)

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(check if address is changed)

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FEC IDENTIFICATION NUMBER

4.

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rHrs sTATEMENT -r-.

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AMENDED {A)

I cerlily that I havo examined this Stalemant and to the best of my knowledge ancl beliel it is tue, coftect and amplete.
Type or Prinl Narne of Treasurer

f-fi"tr',! i Dare iip-,_%

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or incornplete intormation may subjecl the prson signing this Stalemsnt to the penatties ol 2 U.S.C. S4S7g.
ANY CHANGE IN INFORMATION SHOULO BE REPORTED WTHIN 10 DAYS.
For lurthcr lntolmatlon contect:
Fedral El8ction Commission Toll Fre 80G424-9530 Loca! 202-6S+r 100

FEC Form

(Revised

0212009)

page 2

5.

TYPE OF COMMITTEE

Cendidate CmnmiHae:

(a) i*l
(b) ii i:
Name of Candidate
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This committee is a principal campaign commitlee. (Complele lhe candidate intormation below.) This commiltee is an authorized committee, and is NOT a principal campaign committee. (Complete the candidate information below.)

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eartyeiiimrion i,,.,"-==^*ii

Otfice i*., Sought: ,,j

House

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State
District.

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This committee supportyopposes fiiry one candidate, and is NOT an authorized committee.

candidaie

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$iJ"**,"tiffi"ommitree

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(Democratic,

Party Committee:

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(d) itt,i rhis csmmirtee is a fi,$--ffi?

Political Action Committee (PAC):
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orihe f,-if"**

Republican, etc.) Party,

This committee is a separate segrgated fund. (ldentify connected organlzallon on line 6.) Its connected organization is a:

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Corporalion MembershipOrganizalion

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Corporation w/o Capital Stock Trade Asgociaiion

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Labor orsanization cooperativ

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ln addition, this committee is a LobbyisURegistrant PAC.

This committe supportyopposes more than one Fderal candidate, and is NOT a soparat sgr6gar6d lund or party committee. (i.e., nonconnected committee)

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ln addition, this commhtee is a Lobbyist/Registrant PAC. ln addition, this commitlee is a Leadership PAC. (ldentify sponsor on tine 6.)

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Joint Fundralsing Representative:

:i" i This commiltes collects contributions, pays tundraising expenses and disburses nel proceeds tor two or mor political -.=j; committees/qrganizations, al least one of u/hich is an authorized commiuee of a lederal canrJidate.

(h) ii"il ij
:.i.,

This commiltee collecls contributions, pays fundraising expenses and disburses net proceeds for two or more political
commiltees,/organizalions, none of which is an authorized committee of a federal candidate.

Committees Participating in Joint Fundraiser

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6.

FEC Form

(Hevised 02t20091

Page 3

Write or Type Commitlee Name

Name

of Any Connected OrEanizauon, Afliliated Committee, Joint Fundralsing Bepresentative, or Leadership PAC Sponsor

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Mailing Address

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Relationship:

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conn""t"o organization

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Comminee

il.loint Fundraising Flepresentarive l'ir-eaaerstrip PAC Sponsor

Custodlan of Fecorde: ldentify by name, address (phone number books and records.

optional) and position of the person in possession of commiilee

Full Name Mailing Address

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or Position

Tetephonenumber

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Treasuter: List lhe name and address (phone number any designated agenl (e.9., assisiant treasurer).

optional) of the trsasurer of thB committee; and the name and address ot

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Mailing Address

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FEG Form 1 (Revised

02f20o9)

Page

Full Name of
Designated Agent

Mailing Address

AF

CITY
Title or Position

STATE
Tehphononumber

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ZIP CODE

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Banks or Other Depositories: Lisl all banks or other deposilories in which the committee deposits fundq holds accounts, rents safety doposit boxes or maintains ,unds.
Name of Bank, Depository, etc.

63A,Mt*,0,6,
Mailing Address

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CITY
STATE

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ZIP CODE

Federal Election Commission ENVELOPE REPLACEMENT PAGE FOR INCOMING DOCUMENTS The FEC added this page to the end of this filing to indicate how it was received.
Date of Receipt

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Uand Delivered
Postrnarked

USPS First Class Mail

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Postmarked (R/C)
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USPS Registered/Certified

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UseS Express Mail

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Shipping Date Ovemight Delivery Service (Specify):
Next Business Day Delivery

Date of Receipt

neceived from House Records & Registration Office

Date of Receipt

neceived from Senate Public Records Office

Date of Receipt

neceived from Electronic Filing Office

Date of Receipt or Postmarked

[-l

otner (Specify):

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0

z/d,,
DATE PREPARED

PREPARER (3/2005)

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