
COMMITTEE NAME: POLITICAL COMMITTEE IDENTIFICATION No.:
REQUIRED COMMITTEE OFFICERS.
POSITION NAME
MAILING ADDRESS, DAYTIME PHONE NUMBER, AND E-MAIL ADDRESS
CHAIRMAN
TREASURER
POSITION, NAME & MAILING ADDRESS OF EACH CUSTODIAN OF THE COMMITTEE’S BOOKS AND ACCOUNTS.
POSITION NAME
MAILING ADDRESS, DAYTIME PHONE NUMBER, AND E-MAIL ADDRESS
LIST OF ALL FINANCIAL INSTITUTIONS AND OTHER REPOSITORIES OF THE COMMITTEE FUNDS.
(IF AMENDING, LIST ALL AS OF TODAY’S DATE.)
NAME MAILING ADDRESS AND PHONE NUMBER
DISPOSITION OF RESIDUAL FUNDS IN THE EVENT OF DISSOLUTION OR TERMINATION OF THE COMMITTEE:
RETURN TO CONTRIBUTORS IN AMOUNTS NOT TO EXCEED THEIR INDIVIDUAL CONTRIBUTIONS.
TRANSFER TO ANOTHER POLITICAL COMMITTEE:
TRANSFER TO A CHARITABLE ORGANIZATION:
IF MORE SPACE FOR INFORMATION IS REQUIRED, PLEASE ATTACH ADDITIONAL SHEETS.
VERIFICATION- BALLOT INITIATIVE COMMITTEES ONLY
I DECLARE THAT THIS BALLOT INITIATIVE COMMITTEE
IS FORMED FOR THE PURPOSE OF SUPPORTING OR OPPOSING A QUESTION OF PUBLIC POLICY, ALL CONTRIBUTIONS AND
EXPENDITURES OF THE COMMITTEE WILL BE USED FOR THE PURPOSE DESCRIBED IN THIS STATEMENT OF ORGANIZATION, THE COMMITTEE MAY ACCEPT UNLIMITED CONTRIBUTIONS FROM
ANY SOURCE, PROVIDED THAT THIS BALLOT INITIATIVE COMMITTEE DOES NOT MAKE CONTRIBUTIONS OR EXPENDITURES IN SUPPORT OF OR OPPOSITION TO A CANDIDATE OR CANDIDATES
FOR NOMINATION FOR ELECTION, ELECTION, OR RETENTION, AND FAILURE TO ABIDE BY THESE REQUIREMENTS SHALL DEEM THIS COMMITTEE IN VIOLATION OF THIS ARTICLE. (10 ILCS 5/9)
PRINTED AND WRITTEN SIGNATURE OF COMMITTEE CHAIRPERSON DATE
VERIFICATION: INDEPENDENT EXPENDITURE
COMMITTEES ONLY
I DECLARE THAT ( i) THIS INDEPENDENT EXPENDITURE COMMITTEE IS FORMED FOR THE EXCLUSIVE PURPOSE OF MAKING INDEPENDENT EXPEN DITURES, ( ii) ALL CONTRIBUTIONS AND
EXPENDITURES O F THE COMMITTEE WILL BE USED FOR T HE PU RPOSE D ESCRIBED I N T HE ST ATEMENT O F O RGANIZATION, ( iii) T HE C OMMITTEE M AY A CCEPT UNL IMITED CO NTRIBUTIONS
FROM ANY SOURCE, PROVIDED THAT THE INDEPENDENT EXPENDITURE COMMITTEE DOES NOT MAKE CONTRIBUTIONS TO ANY CANDIDATE POLITICAL COMMITTEE, POLITICAL PARTY COMMITTEE,
OR POLITICAL ACTION COMMITTEE, AND (iv) FAILURE TO ABIDE BY THESE REQUIREMENTS SHALL DEEM THE COMMITTEE IN VIOLATION OF THIS ARTICLE.
PRINTED AND WRITTEN SIGNATURE OF COMMITTEE CHAIRPERSON DATE
VERIFICATION: ALL POLITICAL COMMITTEES
I DECLARE THAT THIS STATEMENT OF ORGANIZATION (INCLUDING ANY ACCOMPANYING SCHEDULES AND STATEMENTS) HAS BEEN EXAMINED BY ME AND, TO THE BEST OF MY KNOWLEDGE
AND BELIEF, IS A TRUE, CORRECT, AND COMPLETE STATEMENT OF ORGANIZATION AS REQUIRED BY ARTICLE 9 OF THE ELECTION CODE. I UNDERSTAND THAT WILLFULLY FILING A FALSE OR
INCOMPLETE STATEMENT IS SUBJECT TO A CIVIL PENALTY OF AT LEAST $1001 AND UP TO $5000.
PRINTED AND WRITTEN SIGNATURE OF TREASURER OR CANDIDATE DATE
THE ILLINOIS STATE BOARD OF ELECTIONS REQUIRES THE DISCLOSURE OF INFORMATION THAT IS NECESSARY IF YOU QUALIFY AS A POLITICAL COMMITTEE AS
OUTLINED UNDER PUBLIC ACT 78-1183. WILLFUL FAILURE TO FILE OR WILLFUL FILING OF FALSE OR INCOMPLETE INFORMATION REQUIRED BY THIS ARTICLE SHALL
CONSTITUTE A BUSINESS OFFENSE SUBJECT TO A FINE OF UP TO $5000. THIS FORM IS IN COMPLIANCE WITH THE FORMS MANAGEMENT PROGRAM ACT.
ALL POLITICAL COMMITTEES RETURN TO:
STATE BOARD OF ELECTIONS
2329 S MACARTHUR BLVD
SPRINGFIELD, IL 62704-4503
fax: 217-557-5630
e-mail:
D1@ELECTIONS.IL.GOV(D-1s ONLY)
STATE BOARD OF ELECTIONS
JAMES R. THOMPSON CENTER
100 W RANDOLPH ST, STE 14-100
CHICAGO, IL. 60601-3232
fax: 312-814-6485
e-mail:
D1@ELECTIONS.IL.GOV(D-1s ONLY)
www.elections.il.gov PAGE 2 OF 2