2017 Financial Disclosure Report For a Candidate

Transcription

1 Salt Lake County Clerk 2001 South State Street, Suite #S1100 Salt Lake City, Utah Phone# Fax# Financial Disclosure Report For a Candidate Name Candidate or Officeholder Office Political Party Street Address and Apartment Number City State Zip Code Office Sought District Number Phone Number Fax # Address INTERIM REPORTS: (Required only during election years) April 5 Seven days before a primary election September 15 Seven days before a general election Type Report (Check the appropriate box) YEAR-END REPORT: January 31 each year (Required by all open campaign committees) FINAL / DISSOLUTION REPORT: Final / Dissolution Report The campaign is no longer active or receiving contributions and the campaign account balance is zero. Is this report an amendment? Yes (If yes, date report) No Report Verification I, Print Name Candidate or Officeholder affirm that this Financial Disclosure Report is true, accurate and correct to the best my knowledge. Signature Candidate or Officeholder Date For more information or additional forms, visit or contact the Salt Lake County Clerk, Elections Division at For Office Use Only Entered Copied Date Received

2 Summary Page (Complete this page after filling out Schedule A and Schedule B) Date Report CONTRIBUTIONS RECEIVED Column A Total this Period Column B Aggregate Total 1 TOTAL CONTRIBUTIONS RECEIVED (See Schedule A) EXPENDITURES MADE 2 TOTAL EXPENDITURES MADE (See Schedule B) BALANCE SUMMARY 3 Balance at Beginning Reporting Period Refer to Line 7 on your last report 4 Total Contributions Received (From Line 1 Column A) 5 Subtotal (Add Lines 3and 4) 6 7 Total Expenditures Made (From Line 2 Column A) Balance at Close Reporting Period (Subtract Line 6 from Line 5)

3 Schedule A Itemized Contributions Received Date Report Attach additional pages if needed Date Received Name Contributor Complete Mailing Address Occupation/Employer Amount $ TOTAL CONTRIBUTIONS RECEIVED (Sum subtotals from all Schedule A pages)

4 Schedule B Itemized Expenditures Made Date Report Attach additional pages if needed Date Expenditure Name Recipient Purpose Amount Expenditure TOTAL EXPENDITUTRES MADE (Sum subtotals from all Schedule B pages)

5 Summary Page Other Campaign Accounts Candidate or Officeholder s Last Name Date Report (Complete this page after filling out Itemized Contributions from Other Campaign Accounts and Itemized Expenditures from Other Campaign Accounts. Only candidates with other open campaign accounts that are not County campaign accounts are required to complete these Summary Pages for Other Campaign Accounts). CONTRIBUTIONS RECEIVED 1 TOTAL CONTRIBUTIONS RECEIVED FROM OTHER CAMPAIGN ACCOUNTS EXPENDITURES MADE Column A Total this Period Column B Year to Date 2 TOTAL EXPENDITURES MADE FROM OTHER CAMPAIGN ACCOUNTS BALANCE SUMMARY 3 Balance at Beginning Reporting Period Refer to Line 7 on your last report 4 Total Contributions Received (From Line 1 Column A) 5 Subtotal (Add Lines 3and 4) 6 7 Total Expenditures Made (From Line 2 Column A) Balance at Close Reporting Period (Subtract Line 6 from Line 5)

6 Itemized Contributions from Other Campaign Accounts Attach additional pages or your own spreadsheet if needed Date Received Name Contributor Complete Mailing Address Occupation AND Employer Page Date Report Amount TOTAL CONTRIBUTIONS RECEIVED (Sum subtotals from all Itemized Contributions from Other Campaign Accounts pages)

7 Itemized Expenditures from Other Campaign Accounts Page Date Report Attach additional pages or your own spreadsheet if needed Date Expenditure Name Recipient Purpose Amount TOTAL EXPENDITUTRES MADE (Sum subtotals from all Itemized Expenditures from Other Campaign Accounts pages)