Slate Mailer Organization Campaign Statement

Form 401 Instructions

Amendment

Amendment
Explain Reason For Amendment:

Statement Covers Period

From:
Through:

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Part 1 of 9: Slate Mailer Organization Information

Information About Slate Mailer Organization

Full Name of Slate Mailer Organization:
Address:
City:
State:
Zip Code:
Area Code:
Phone Number:
ID Number:
Name of Treasurer:
Treasurer's Address:
Treasurer's City:
Treasurer's State:
Treasurer' Zip Code:
Treasurer's Area Code:
Treasurer's Phone Number:

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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.

Committee Report Attached
ID Number if Recipient Committee:

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Part 3 of 9: Summary of Payments

Total This Period

Total Payments Recieved:
Total Payments Made:

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

Total Payments Recieved:
Total Payments Made:

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Part 4 of 9: Verification

Verify

Executed On:
At:
Name of Responsible Officer:
Title:

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Part 5a of 9: Schedule A - Payments Received

First Payments Received

Date Reveived:
Identification of Persons From Whom $100 or More Has Been Recieved This Period
Name, Office Sought, and Jurisdiction of Candidate/Ballot Measure Supported or Opposed
Support
Oppose Amount Received This Period:
Cumulative Amount Received Since January 1 Per Candidate or Measure:

Second Payments Received

Date Reveived:
Identification of Persons From Whom $100 or More Has Been Recieved This Period
Name, Office Sought, and Jurisdiction of Candidate/Ballot Measure Supported or Opposed
Support
Oppose Amount Received This Period:
Cumulative Amount Received Since January 1 Per Candidate or Measure:

Third Payments Received

Date Reveived:
Identification of Persons From Whom $100 or More Has Been Recieved This Period
Name, Office Sought, and Jurisdiction of Candidate/Ballot Measure Supported or Opposed
Support
Oppose Amount Received This Period:
Cumulative Amount Received Since January 1 Per Candidate or Measure:

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Subtotal

Subtotal for First Through Third Payments Recieved:

Fourth Payments Received

Date Reveived:
Identification of Persons From Whom $100 or More Has Been Recieved This Period
Name, Office Sought, and Jurisdiction of Candidate/Ballot Measure Supported or Opposed
Support
Oppose Amount Received This Period:
Cumulative Amount Received Since January 1 Per Candidate or Measure:

Fifth Payments Received

Date Reveived:
Identification of Persons From Whom $100 or More Has Been Recieved This Period
Name, Office Sought, and Jurisdiction of Candidate/Ballot Measure Supported or Opposed
Support
Oppose Amount Received This Period:
Cumulative Amount Received Since January 1 Per Candidate or Measure:

Sixth Payments Received

Date Reveived:
Identification of Persons From Whom $100 or More Has Been Recieved This Period
Name, Office Sought, and Jurisdiction of Candidate/Ballot Measure Supported or Opposed
Support
Oppose Amount Received This Period:
Cumulative Amount Received Since January 1 Per Candidate or Measure:

Seventh Payments Received

Date Reveived:
Identification of Persons From Whom $100 or More Has Been Recieved This Period
Name, Office Sought, and Jurisdiction of Candidate/Ballot Measure Supported or Opposed
Support
Oppose Amount Received This Period:
Cumulative Amount Received Since January 1 Per Candidate or Measure:

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Subtotal

Subtotal for Fourth through Seventh Payments Recieved:

Part 5b of 9: Summary of Schedule A

1. Amount Received - Iteminized Payments:
2. Amount Received - Payments of less than $100:
3. Total Payments Received:

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Part 6a of 9: Schedule B - Payments Made

First Payment Made

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Second Payment Made

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Third Payment Made

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Fourth Payment Made

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Fifth Payment Made

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Sixth Payment Made

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

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Subtotal

Subtotal for Payments Made:

Part 6b of 10: Summary of Schedule B

1. Payments of $100 or More
2. Payments Under $100 This Period:
Total Payments This Period:

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

Name of Agent or Independent Contractor

First Agent or Independent Contractor

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Second Agent or Independent Contractor

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Third Agent or Independent Contractor

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Fourth Agent or Independent Contractor

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Fifth Agent or Independent Contractor

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

Sixth Agent or Independent Contractor

Name and Street Address of Payee:
Description of Payment:
Amount Paid:

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Total of Amounts Paid:

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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

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Second Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Third Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Fourth Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Fifth Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Sixth Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Seventh Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Eight Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Ninth Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Tenth Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

Eleventh Persons Receiving

Names of Individuals Receiving $1,000 or More:
Amount This Period:
Cumulative Since January 1:

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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

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Second Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Third Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Fourth Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Fifth Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Sixth Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Seventh Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Eigth Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Ninth Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Tenth Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Eleventh Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

Twelfth Candidate or Measure

Name of Candidate or Measure:
Support
Oppose Jurisdiction and Office Sought by Candidate or Jurisdiction and Ballot Measure Letter or Number:

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