Form 8872 (Rev. October 2014) - Internal Revenue Service

1 form 8872(Rev. October 2014 )Department of the Treasury Internal Revenue ServicePolitical Organization Report of Contributions and Expenditures Information about form 8872 and its instructions is available at Do not enter social security numbers on this form or any attachments to it as they may be made public. OMB No. 1545-0123 Open to Public InspectionAFor the period beginning, 20and ending, 20 BCheck applicable boxes:Initial reportChange of addressAmended reportFinal report1 Name of organization Employer identification number 2 Mailing address ( Box or number, street, and room or suite number)City or town, state or province, country, and ZIP or foreign postal code3 Email address of organization4 Date organization was formed5aName of custodian of records5b Custodian's address6aName of contact person6b Contact person's address7 Business address of organization (if different from mailing address shown above).

2 Number, street, and room or suite numberCity or town, state or province, country, and ZIP or foreign postal code8 Type of report (check only one box)aFirst quarterly report (due by April 15)bSecond quarterly report (due by July 15)cThird quarterly report (due by October 15)dYear-end report (due by January 31)eMid-year report (Non-election year only due by July 31)fMonthly report for the month of: (due by the 20th day following the month shown above, except the December report, which is due by January 31)gPre-election report (due by the 12th or 15th day before the election)(1)Type of election:(2)Date of election:(3)For the state of:hPost-general election report (due by the 30th day after general election)(1)Date of election:(2)For the state of:9 Total amount of reported contributions (total from all attached Schedules A).

3 910 Total amount of reported expenditures (total from all attached Schedules B)..10 Sign Here Under penalties of perjury, I declare that I have examined this report, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Signature of authorized official Date For Paperwork Reduction Act Notice, see separate No. 30406 GForm 8872 (Rev. 10- 2014 ) form 8872 (Rev. 10- 2014 )Schedule AItemized Contributions (DO NOT enter social security numbers on this schedule.)Schedule A page of Name of organization Employer identification number Contributor's name, mailing address and ZIP codeName of contributor's employerContributor's occupationAggregate contributions $Amount of contribution$Date of contributionContributor's name, mailing address and ZIP codeName of contributor's employerContributor's occupationAggregate contributions $Amount of contribution$Date of contributionContributor's name, mailing address and ZIP codeName of contributor's employerContributor's occupationAggregate contributions $Amount of contribution$Date of contributionContributor's name.

4 Mailing address and ZIP codeName of contributor's employerContributor's occupationAggregate contributions $Amount of contribution$Date of contributionContributor's name, mailing address and ZIP codeContributor's occupationName of contributor's employerAggregate contributions $Amount of contribution$Date of contributionContributor's name, mailing address and ZIP codeName of contributor's employerContributor's occupationAggregate contributions $Amount of contribution$Date of contributionContributor's name, mailing address and ZIP codeName of contributor's employerContributor's occupationAggregate contributions $Amount of contribution$Date of contributionContributor's name, mailing address and ZIP codeName of contributor's employerContributor's occupationAggregate contributions $Amount of contribution$Date of contributionContributor's name, mailing address and ZIP codeName of contributor's employerContributor's occupationAggregate contributions $Amount of contribution$Date of contributionSubtotal of contributions reported on this page only.

5 Enter here and also include this amount in the total on line 9 of form $ form 8872 (Rev. 10- 2014 )Open to Public InspectionForm 8872 (Rev. 10- 2014 )Schedule BItemized Expenditures (DO NOT enter social security numbers on this schedule.)Schedule B page of Name of organization Employer identification number Recipient's name, mailing address and ZIP codeName of recipient's employerRecipient's occupationAmount of expenditure$Date of expenditurePurpose of expenditure Recipient's name, mailing address and ZIP codeName of recipient's employerRecipient's occupationAmount of expenditure$Date of expenditurePurpose of expenditure Recipient's name, mailing address and ZIP codeName of recipient's employerRecipient's occupationAmount of expenditure$Date of expenditurePurpose of expenditure Recipient's name, mailing address and ZIP codeName of recipient's employerRecipient's occupationAmount of expenditure$Date of expenditurePurpose of expenditure Recipient's name.

6 Mailing address and ZIP codeName of recipient's employerRecipient's occupationAmount of expenditure$Date of expenditurePurpose of expenditure Recipient's name, mailing address and ZIP codeName of recipient's employerRecipient's occupationAmount of expenditure$Date of expenditurePurpose of expenditure Subtotal of expenditures reported on this page only. Enter here and also include this amount in the total on line 10 of form $ form 8872 (Rev. 10- 2014 )Open to Public Inspectio