Slate Mailer Organization Campaign Statement

Form 401 Instructions

Amendment



Statement Covers Period




Part 1 of 9: Slate Mailer Organization Information

Information About Slate Mailer Organization

















Part 2 of 9: Is This a General Purpose Committe?

General Purpose Committee

If this Slate Mailer Organization is also a “general purpose committee” as defined in Government Code Section 82027.5, check box and attach the committee’s campaign disclosure report to this statement.




Part 3 of 9: Summary of Payments

Total This Period



Cumulative to Date (Since January 1 of calendar year covered)




Part 4 of 9: Verification

Verify






Part 5a of 9: Schedule A - Payments Received

First Payments Received







Second Payments Received







Third Payments Received








Subtotal


Fourth Payments Received







Fifth Payments Received







Sixth Payments Received







Seventh Payments Received








Subtotal


Part 5b of 9: Summary of Schedule A





Part 6a of 9: Schedule B - Payments Made

First Payment Made




Second Payment Made




Third Payment Made




Fourth Payment Made




Fifth Payment Made




Sixth Payment Made





Subtotal


Part 6b of 10: Summary of Schedule B





Part 7 of 9: Schedule B-1 - Payments Made By An Angent or Independent Contractor on Behalf of a Slate Mailer Organization


First Agent or Independent Contractor




Second Agent or Independent Contractor




Third Agent or Independent Contractor




Fourth Agent or Independent Contractor




Fifth Agent or Independent Contractor




Sixth Agent or Independent Contractor







Part 8 of 9: Schedule C - Persons Receiving $1,000 or More

You must identify each individual listed on your Statement of Organization (Form 400) who received, directly or indeirectly, $1,000 or more from the organization during the period. See instructions regarding "indirect" payments.

First Persons Receiving




Second Persons Receiving




Third Persons Receiving




Fourth Persons Receiving




Fifth Persons Receiving




Sixth Persons Receiving




Seventh Persons Receiving




Eight Persons Receiving




Ninth Persons Receiving




Tenth Persons Receiving




Eleventh Persons Receiving





Part 9 of 9: Schedule D - Candidates and Measures Not Listed on Schedule A

You must identify each candidate and measure supported or opposed in a slate mailer sent by you during the period for which you did not received a payment of $100 or more either from the candidate or ballot measure committee or from any other person.

First Candidate or Measure




Second Candidate or Measure




Third Candidate or Measure




Fourth Candidate or Measure




Fifth Candidate or Measure




Sixth Candidate or Measure




Seventh Candidate or Measure




Eigth Candidate or Measure




Ninth Candidate or Measure




Tenth Candidate or Measure




Eleventh Candidate or Measure




Twelfth Candidate or Measure




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