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## COVER SHEET CAMPAIGN DISCLOSURE REPORT FOR THE PERIOD ENDING: NAME OF CANDIDATE OR COMMITTEE ## Summary Page REPORT OF RECEIPTS AND DISBURSEMENTS For an Authorized Committee (Summary Page) 1. Name of Candidate or Committee (in Full) 2. Report Identification No. Address (number and street) 3. Is this report an amendment Yes City, Island and Zip Code No January Semi Annual Report Primary Election Report June Semi Annual Report General Election Report Special Election Report Runoff Election Report 4. Covering Period through This Period Calendar Year-to-Date 5. Beginning Cash on Hand Balance 0 0 6. Total Contributions, loans & Receipts (Form 1) 7. Total Operating Expenditures (Form 2) 8. Ending Cash on Hand Balance 9. Debts and Obligations a. Total loan amounts (Form 3) 0 0 b. Total Contributions Receivable (Form 4) 0 0 c. Total Expenditures Payable (Form 5) 0 0 I certify that I have examined this Report and to the best of my knowledge and belief it is true, correct and complete. Signature of Candidate or Treasurer Date ## Detail Summary Page Detailed Summary Page of Receipts and Disbursement Name of Candidate or Committee (in Full) Receipts 10. CONTRIBUTIONS, LOANS & RECEIPTS This Period Year-to-Date a. Individuals/Persons other than political committees 0 (Form 1 - A) b. Political Party Committees 0 0 (Form 1 - B) c. Other Political Committees (such as PAC's) (Form 1 - C) d. The Candidate (Form 1 - D) e. Contributions from other Authorized Committees 0 0 (Form 1 - E) f. Loans made or guaranteed by the Candidate 0 0 (Form 1 - F) g. All other loans 0 0 (Form 1 - F) h. Other Receipts (Form 1 - G) TOTAL CONTRIBUTIONS, LOANS & RECEIPTS 11. DISBURSEMENTS a. Operating Expenditures (Form 2 - A) b. Other Disbursements (Form 2 - B) TOTAL DISBURSEMENTS 12. Cash on Hand last Reporting Period Cash on Hand this Reporting Period I certify that I have examined this Report and to the best of my knowledge and belief it is true, correct and complete. Signature of Candidate or Treasurer Date ## Form 1-A CONTRIBUTIONS INDIVIDUALS/PERSONS OTHER THAN POLITICAL COMMITTEES (FORM 1-A) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Contributors: Full Name Mailing address Principal Place of Business Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Full Name Mailing address Principal Place of Business Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Full Name Mailing address Principal Place of Business Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Full Name Mailing address Principal Place of Business Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) ## Form 1-B CONTRIBUTIONS POLITICAL PARTY COMMITTEES (FORM 1-B) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Contributors: Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) ## Form 1-C CONTRIBUTIONS OTHER POLITICAL COMMITTEES (such as PAC's) (FORM 1-C) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Contributors: Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) ## Form 1-D CONTRIBUTIONS THE CANDIDATE (FORM 1-D) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution Date of contribution Amount contributed Purpose of contribution ## Form 1-E CONTRIBUTIONS OTHER AUTHORIZED COMMITTEES (FORM 1-E) (Please attach copies of checks, money orders or receipts for your back-up information) Name of Candidate or Committee (in Full) Contributors: Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) Committee Name Name and Title of Committee Member Receiving Transfer Type of document by which Transfer was made Amount contributed this report period Date of Contribution Aggregate amount of contribution (Year-to-Date) ## Form 1-F CONTRIBUTIONS LOANS MADE OR GUARANTEED BY THE CANDIDATE (FORM 1-F) (Please attach copies of loan agreements, promissory notes and /or other relavant documents) Name of Candidate or Committee (in Full) Loans: Name of Lender Loan amount Loan terms of repayment Loan period Date of Loan Aggregate amount of Loan (Year-to-Date) Name of Lender Loan amount Loan terms of repayment Loan period Date of Loan Aggregate amount of Loan (Year-to-Date) ALL OTHER LOANS Name of Lender Loan amount Loan terms of repayment Loan period Date of Loan Aggregate amount of Loan (Year-to-Date) Name of Lender Loan amount Loan terms of repayment Loan period Date of Loan Aggregate amount of Loan (Year-to-Date) ## Form 1-G CONTRIBUTIONS OTHER RECEIPTS (FORM 1-G) (Please attach one (1) original document for proof of event (such as a food sale ticket) for your back-up info.) Name of Candidate or Committee (in Full) Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 1 Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 2 Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 3 Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 4 Location and Type of Event Date of Event Amount of Ticket Sales Amount from Mass Collections Total 5 PAGE TOTAL GRAND TOTAL ## TOTAL CONTR. (Form 1) TOTAL SUM OF CONTRIBUTIONS, LOANS & RECEIPTS (FORM 1) Name of Candidate or Committee (in Full) It is hereby certified that during the period to , the total sum of was contributed to the candidate or committee identified above, and that the person or persons making the contribution(s) are listed regardless of the amount contributed. It is hereby certified that during the period to , the total sum of was Loaned to the candidate or committee identified above, and that the person or persons making the loan(s) are listed regardless of the amount loaned. It is hereby certified that during the period to , the total sum of was received by the candidate or committee identified above, and that the events or fundraising activities where these receipts were collected are listed regardless of the amount received. Signature of Candidate or Treasurer ## Form 2-A ITEMIZED EXPENDITURES (FORM 2-A) (Please attach copies of checks, invoices, receipts and all documents to support all expenditures) Name of Candidate or Committee (in Full) Full Name, Mailing Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 1 Full Name, Mailing Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 2 Full Name, Mailing Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 3 Full Name, Mailing Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 4 Full Name, Mailing Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 5 Full Name, Mailing Address and Zip Code Date of Expenditure Purpose of Expenditure Amount of Expenditure 6 PAGE TOTAL GRAND TOTAL ## Form 2-B OTHER DISBURSEMENTS (FORM 2-B) (Please attach copies of checks, invoices, receipts and all documents to support all expenditures) Name of Candidate or Committee (in Full) Full Name, Mailing Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 1 Full Name, Mailing Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 2 Full Name, Mailing Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 3 Full Name, Mailing Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 4 Full Name, Mailing Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 5 Full Name, Mailing Address and Zip Code Date of Disbursement Purpose of Disbursement Amount of Disbursment 6 PAGE TOTAL GRAND TOTAL ## TOTAL EXP. (Form 2) TOTAL SUM OF EXPENDITURES & OTHER DISBURSMENTS (FORM 2) Name of Candidate or Committee (in Full) It is hereby certified that during the period to , the total sum of was expended in accordance with the provision of Title 18 Section 905 of the Virgin Islands Code and that each expenditure was reported regardless of the amount expended. Signature of Candidate or Treasurer ## Receivables DEBTS AND OBLIGATIONS CONTRIBUTIONS RECEIVABLE (Please attach copies of checks, invoices, receipts and all supporting documents) Name of Candidate or Committee (in Full) Full and Complete Identification of Receivables due to the Committee Date of Receivable Circumstance and conditions of the Receivable Amount of Receivable 1 Full and Complete Identification of Receivables due to the Committee Date of Receivable Circumstance and conditions of the Receivable Amount of Receivable 2 Full and Complete Identification of Receivables due to the Committee Date of Receivable Circumstance and conditions of the Receivable Amount of Receivable 3 Full and Complete Identification of Receivables due to the Committee Date of Receivable Circumstance and conditions of the Receivable Amount of Receivable 4 Full and Complete Identification of Receivables due to the Committee Date of Receivable Circumstance and conditions of the Receivable Amount of Receivable 5 Full and Complete Identification of Receivables due to the Committee Date of Receivable Circumstance and conditions of the Receivable Amount of Receivable 6 PAGE TOTAL GRAND TOTAL ## Payables DEBTS AND OBLIGATIONS EXPENDITURES PAYABLE (Please attach copies of checks, invoices, receipts and all supporting documents) Name of Candidate or Committee (in Full) Full and Complete Identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amount of Payable 1 Full and Complete Identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amount of Payable 2 Full and Complete Identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amount of Payable 3 Full and Complete Identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amount of Payable 4 Full and Complete Identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amount of Payable 5 Full and Complete Identification of Payable due from the Committee Date of Payable Circumstance and conditions of Payable Amount of Payable 6 PAGE TOTAL GRAND TOTAL ## Non-Monetary NON-MONETARY CONTRIBUTIONS (ITEMS) (Please attach copies of invoices, receipts and all supporting documents) Name of Candidate or Committee (in Full) Full Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 1 Full Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 2 Full Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 3 Full Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 4 Full Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 5 Full Name, Mailing Address and Zip Code Date Contribution Made Type of Contribution Value of Contribution 6 PAGE TOTAL GRAND TOTAL ## Election use only *********NOTE*********** PLEASE ENCLOSE COPIES OF BANK STATEMENTS, RECIEPTS, INVOICES, PROMISSORY NOTE, AND OTHER SUPPORTING DOCUMENTATION. DO NOT WRITE ON THIS PAGE, ELECTION USE ONLY!!! RECEIVED FROM NAME OF CANDIDATE OR COMMITTEE REPORTING PERIOD DATE ELECTION OFFICIAL'S SIGNATURE ## Instructions INSTRUCTIONS FOR THE COMPLETION OF THE CAMPAIGN DISCLOSURE FORMS 1 Reporting Forms: a) Campaign Disclosure forms should be typed; printing in ink is also acceptable as long as the forms are legiable. All document sent to the Supervisor of Elections must be orginials. b) All reports must be on the forms prescribed by the Supervisor of Elections. c) Computerized forms are acceptable as long as they are in the same format and style as the forms prescribed by the Supervisor of Elections. 2 Special Rules for First Report: a) In the first report filed after registering as a political committee, the principal campaign committee must disclose all financial activitiy that occurred before registration and before the individual became a candidate (including any testing the water activity). 3 Cash on Hand: a) A committee must report the cash on hand it possessed at both the beginning of the reporting period and the close of the reporting period. Note that the closing cash balance for the current reporting period appears on the next report as beginning the cash on hand. Cash on hand includes petty cash. 4 How to Itemize Receipts: a) Committees must report receipts under the different categories listed on the Detailed Summary Page (3). For each category, a committee must disclose the total for the current reporting period and the year-to-date total. In addition to reporting these totals, a committee often has to itemize receipts by providing supplemental information on supporting form 1. Four types of receipts listed on the Detail Summary Page must be itemized regardless of amount: * Contributions from party committee * Contributions from others committees * Transfers: and * Loans. Aggregation: Calendar Year vs. Election Note that authorized committees must aggregate contributions on a per election basis when monitoring contribution limits. For purposes of reporting, however, committees aggregate contributions and other receipts on a calendar year basis. 5 Special Rules for Certain Receipts: In-kind contributions: When determining whether to itemize an in-kind contribution, a committee should treat it the same as a monetary contribution. The only difference is that the amount of an in-kind contribution must also be included in the committee’ s total operating expenditure in order to avoid inflating cash on hand. 6 Loans: All loans received by a committee must be itemized and continuously reported until repaid. All repayments made on a loan must also be itemized.