Independent Expenditure Report

Amounts may be rounded to whole dollars.

Form 496 Instructions

Part 1 of 3: List Only One Candidate or Ballot Measure

Candidate Supported or Opposed


Ballot Measure Supported or Opposed


Part 2 of 3: Independent Expenditures Made

Attach additional information on appropriately labeled continuation sheets.

First Independent Expenditure Made

Second Independent Expenditure Made

Third Independent Expenditure Made

Fourth Independent Expenditure Made

Reason for Amendment

Part 3 of 3: Contributions of $100 or More Recieved

Major donor and independent expenditure committees that do not receive contributions are not required to complete Part 3.

First Contribution

Contributor Code:

Second Contribution

Contributor Code:

Third Contribution

Contributor Code:

Fourth Contribution

Contributor Code

Fifth Contribution

Contributor Code

Sixth Contribution

Contributor Code

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End of Page, Form 496 - Independent Expenditure Report.