Free candr2010.indd - Wyoming

STATEMENT OF RECEIPTS ONLY
CANDIDATE'S AND CANDIDATE'S CAMPAIGN COMMITTEE W.S. 22-25-106 through W.S. 22-25-109
Each candidate and each candidate's committee is required to file a fully itemized statement of receipts at least seven (7) days before any primary, general or special election with information required current to any day from the eighth day up to the fourteenth day before the election The general rule is that candidates and committees should note and keep track of all campaign contributions no matter how small. The law only requires you to itemize on this form contributions (receipts) totaling $25.00 or more. However, please keep in mind that if you receive $10.00 from a contributor who then later gives you $20.00, you must report the total $30.00 contribution on this form. A candidate who fails to file the statement of receipts required by the seventh day before the election, shall have his name printed on a list as specified under W.S. 22-25-108. The list shall be posted and made available to the public. A violation of the campaign reporting provisions of the Wyoming Election Code may constitute a misdemeanor and be punishable by a fine as provided by W.S. 22-26-112. Failure to file within one month of the report due date will make the candidate ineligible to run as a candidate for any state or local office, for which a statement is required, for five (5) years or until the required statement is filed. As provided in W.S. 22-25-109, the secretary of state shall report the names of all candidates in violation of the Election Code of the state of Wyoming to the attorney general or to the district attorney for appropriate action.

Filing Deadlines g Primary Election: Receipts only - before Primary Election - August 10, 2010 (at least 7 days before Primary Election.) p y General Election: Receipts only - before General Election - October 26, 2010 (at least 7 days before General Election.) p y Special Election: Receipts only - (at least seven (7) days before the election.) p y Filing Offices g County Clerk y Candidates for district attorney, county and municipal offices, magistrates, school and community college district trustees. Mail to local County Clerk's Office. Contact information can be accessed on our website under Elections at http://soswy.state.wy.us p y y

This form can be accessed on the Secretary of State's website under Forms & Filings: http://soswy.state.wy.us
5/2009 candr

For Office Use Only

RECEIPTS REPORT
Statement covers period: From: To:

Type of Report: (Check One) Pre-Primary Receipts Report - August 10, 2010 Pre-General Receipts Report - October 26, 2010 Pre-Special Election Amendment Name of Candidate or Committee Office Sought Residence & Mailing Address City Summary for this filing period:

State

Zip

Phone

If you have no receipts to report for this filing period check here and sign below

A.

Receipts 1. 2. 3. Personal Contributions by Candidate (page 2)
(Including candidate's immediate family)

$ $ $ $ $ $ $ $ $

Contributions from Individuals (page 3) Contributions from PACs (page 4)

4. Contributions from Political Parties (page 4) 5. 6. 7. 8. Anonymous Contributions (page 5) In-Kind Contributions (page 5) Loans (page 6) Unitemized receipts (page 6)
(Unitemized receipts are defined as contributions less than $25)

B.

Total Receipts for this Filing Period (Sum of A1-A8)

I certify that I have examined this statement, and to the best of my knowledge and belief, it is true, correct and complete.

Signature of Chairman (Required)

Signature of Candidate
(Required if candidate does not file separately)

Signature of Treasurer (Required)

Date

1

Itemization of Receipts
(Use Additional Sheets as Necessary)

RECEIPTS
Personal Contributions by Candidate
(Including candidate's immediate family)

Name

Address
(City, State & Zip)

Date

Amount

2

Contributions from Individuals
(Contributions from corporations, unions, partnerships and associations are prohibited. Contributions from sole proprietorships are legal, but must be identified as such.)

Name

Address
(City, State & Zip)

Date

Amount

3

Contributions from Political Action Committees
Name (Identify by full name) Address
(City, State & Zip)

Date

Amount

Contributions from Political Party Central Committees
Name Address
(City, State & Zip)

Date

Amount

4

Anonymous Contributions
Anonymous contributions are those contributions whose origins cannot be determined, i.e., "pass the hat" contributions. An anonymous contribution does not mean a contributor may donate to the candidate or PAC with the understanding the contributor's name will not be reported. Event Date Amount

I do not know, nor can I ascertain, the origin of the above anonymous contributions.

Candidate, Chairman or Treasurer

In-Kind Contributions
Name Address
(City, State & Zip)

Date

Description of Contribution

Value or Amount

5

Loans/Obligations

Date

Amount

Unitemized Receipts
(Receipts under $25.00. For example, you have a chili dinner. Tickets are $10.00 each and you sell 500 tickets. You may report these in aggregate here by reporting $5,000.00.) Event (if applicable) Date Amount

6