C

 M M / D D / Y Y Y Y

 M M / D D / Y Y Y Y

 M M / D D / Y Y Y Y M M / D D / Y Y Y Y

 M M / D D / Y Y Y Y

FEC 

FORM 3

1. NAME OF 

 COMMITTEE (in full)

ADDRESS (number and street)

 Check if different 

 than previously 

 reported. (ACC)

FEC FORM 3

(Revised 05/2016)

Office 

Use 

Only

NOTE: Submission of false, erroneous, or incomplete information may subject the person signing this Report to the penalties of 52 U.S.C. §30109. 

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

Type or Print Name of Treasurer

Signature of Treasurer Date

4. TYPE OF REPORT (Choose One)

 (a) Quarterly Reports:

12-Day PRE-Election Report for the:

Primary (12P) General (12G) Runoff (12R)

Convention (12C) Special (12S)

30-Day POST-Election Report for the:

General (30G) Runoff (30R) Special (30S)

CITY STATE ZIP CODE

2. FEC IDENTIFICATION NUMBER

3. IS THIS NEW AMENDED

 REPORT (N) OR (A)

in the 

Election on State of



TYPE OR PRINT

REPORT OF RECEIPTS 

AND DISBURSEMENTS

For An Authorized Committee

5. Covering Period through





in the 

Election on State of

STATE DISTRICT

 

Office Use Only



April 15 Quarterly Report (Q1)

July 15 Quarterly Report (Q2)

October 15 Quarterly Report (Q3)

January 31 Year-End Report (YE)

Termination Report (TER) 

(b) 

 Example: If typing, type 

over the lines.

(c) 

12FE4M5
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COLUMN B

Election Cycle-to-Date

COLUMN A

This Period

6. Net Contributions (other than loans)

 (a) Total Contributions 

 (other than loans) (from Line 11(e)) ....

 (b) Total Contribution Refunds 

 (from Line 20(d)) ..................................

 (c) Net Contributions (other than loans) 

 (subtract Line 6(b) from Line 6(a)) ......

7. Net Operating Expenditures

 (a) Total Operating Expenditures 

 (from Line 17) ......................................

 (b) Total Offsets to Operating 

 Expenditures (from Line 14)................

 (c) Net Operating Expenditures 

 (subtract Line 7(b) from Line 7(a)) ......

8. Cash on Hand at Close of 

 Reporting Period (from Line 27).................

9. Debts and Obligations Owed TO

 the Committee (Itemize all on

 Schedule C and/or Schedule D) ................

10. Debts and Obligations Owed BY

 the Committee (Itemize all on

 Schedule C and/or Schedule D) ................

FEC Form 3 (Revised 03/2016) Page 2

SUMMARY PAGE

of Receipts and Disbursements

Report Covering the Period: From: To:

Write or Type Committee Name

For further information, contact the Federal Election Commission at 800-424-9530 or visit www.fec.gov.
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COLUMN B

Election Cycle-to-Date

COLUMN A

Total This Period

11. CONTRIBUTIONS (other than loans) FROM:

 (a) Individuals/Persons Other Than 

 Political Committees

 (i) Itemized (use Schedule A) ...........

 (ii) Unitemized ....................................

 (iii) TOTAL of contributions 

 from individuals .......................

 (b) Political Party Committees.................

 (c) Other Political Committees 

 (such as PACs) ...................................

 (d) The Candidate ....................................

 (e) TOTAL CONTRIBUTIONS 

 (other than loans) 

 (add Lines 11(a)(iii), (b), (c), and (d))..

12. TRANSFERS FROM OTHER 

 AUTHORIZED COMMITTEES ....................

13. LOANS:

 (a) Made or Guaranteed by the 

 Candidate............................................

 (b) All Other Loans...................................

 (c) TOTAL LOANS 

 (add Lines 13(a) and (b))....................

14. OFFSETS TO OPERATING 

 EXPENDITURES 

 (Refunds, Rebates, etc.) ............................

15. OTHER RECEIPTS 

 (Dividends, Interest, etc.) ...........................

16. TOTAL RECEIPTS (add Lines 

 11(e), 12, 13(c), 14, and 15) 

 (Carry Total to Line 24, page 4)............

DETAILED SUMMARY PAGE

of Receipts

I. RECEIPTS

FEC Form 3 (Revised 05/2016) Page 3





Report Covering the Period: From: To:

Write or Type Committee Name
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COLUMN B

Election Cycle-to-Date

COLUMN A

Total This Period

17. OPERATING EXPENDITURES.....................

18. TRANSFERS TO OTHER 

 AUTHORIZED COMMITTEES .....................

19. LOAN REPAYMENTS:

 (a) Of Loans Made or Guaranteed

 by the Candidate.................................

 (b) Of All Other Loans ..............................

 (c) TOTAL LOAN REPAYMENTS 

 (add Lines 19(a) and (b)).....................

20. REFUNDS OF CONTRIBUTIONS TO:

 (a) Individuals/Persons Other 

 Than Political Committees ..................

 (b) Political Party Committees..................

 (c) Other Political Committees 

 (such as PACs) ....................................

 (d) TOTAL CONTRIBUTION REFUNDS 

 (add Lines 20(a), (b), and (c))..............

21. OTHER DISBURSEMENTS .........................

22. TOTAL DISBURSEMENTS 

 (add Lines 17, 18, 19(c), 20(d), and 21)

II. DISBURSEMENTS

DETAILED SUMMARY PAGE

of Disbursements FEC Form 3 (Revised 05/2016) Page 4

III. CASH SUMMARY

23. CASH ON HAND AT BEGINNING OF REPORTING PERIOD...............................................

24 TOTAL RECEIPTS THIS PERIOD (from Line 16, page 3).....................................................

25. SUBTOTAL (add Line 23 and Line 24) ..................................................................................

26. TOTAL DISBURSEMENTS THIS PERIOD (from Line 22)......................................................

27. CASH ON HAND AT CLOSE OF REPORTING PERIOD 

 (subtract Line 26 from Line 25)..............................................................................................

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SCHEDULE A (FEC Form 3)

ITEMIZED RECEIPTS

Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions 

or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.

NAME OF COMMITTEE (In Full)

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SUBTOTAL of Receipts This Page (optional) ............................................................................    , , .

TOTAL This Period (last page this line number only) ............................................................... 



 Full Name (Last, First, Middle Initial)

 Mailing Address

 City State Zip Code

Receipt For: 

 Primary General

 Other (specify)

A.

Election Cycle-to-Date 

Date of Receipt

Name of Employer Occupation

    , , .

FEC ID number of contributing

federal political committee. C

 Full Name (Last, First, Middle Initial)

 Mailing Address

 City State Zip Code

Receipt For: 

 Primary General

 Other (specify)

B.

Election Cycle-to-Date 

Date of Receipt

Name of Employer Occupation

    , , .

FEC ID number of contributing

federal political committee. C

 Full Name (Last, First, Middle Initial)

 Mailing Address

 City State Zip Code

Receipt For: 

 Primary General

 Other (specify)

C.

Election Cycle-to-Date 

Date of Receipt

Name of Employer Occupation

    , , .

FEC ID number of contributing

federal political committee. C

FOR LINE NUMBER: PAGE OF

Use separate schedule(s) (check only one)

for each category of the 

Detailed Summary Page 11a 11b 11c 11d

 12 13a 13b 14 15

 M M / D D / Y Y Y Y

 M M / D D / Y Y Y Y

 M M / D D / Y Y Y Y

Amount of Each Receipt this Period

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Amount of Each Receipt this Period

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Amount of Each Receipt this Period

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FEC Schedule A (Form 3) (Revised 05/2016)

Memo Item

Memo Item

Memo Item
SCHEDULE B (FEC Form 3)

ITEMIZED DISBURSEMENTS

Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions 

or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee.

NAME OF COMMITTEE (In Full)

    , , .

    , , . SUBTOTAL of Disbursements This Page (optional) .......................................................................

TOTAL This Period (last page this line number only) .................................................................... 



FEC Schedule B (Form 3) (Revised 05/2016)

 Full Name (Last, First, Middle Initial)

 Mailing Address

 City State Zip Code

A. Date of Disbursement

 Full Name (Last, First, Middle Initial)

 Mailing Address

 City State Zip Code

B. Date of Disbursement

 Full Name (Last, First, Middle Initial)

 Mailing Address

 City State Zip Code

C. Date of Disbursement

Purpose of Disbursement

Candidate Name

Office Sought: House

 Senate

 President

State: District:

FOR LINE NUMBER: PAGE OF

Use separate schedule(s) (check only one)

for each category of the 

Detailed Summary Page

Category/

Type

17 18 19a 19b

20a 20b 20c 21

Disbursement For: 

 Primary General

 Other (specify) 

Purpose of Disbursement

Candidate Name

Office Sought: House

 Senate

 President

State: District:

Category/

Type

Disbursement For: 

 Primary General

 Other (specify) 

Purpose of Disbursement

Candidate Name

Office Sought: House

 Senate

 President

State: District:

Category/

Type

Disbursement For: 

 Primary General

 Other (specify) 

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 M M / D D / Y Y Y Y

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Amount of Each Disbursement this Period

Amount of Each Disbursement this Period

Amount of Each Disbursement this Period

FEC Identification Number

FEC Identification Number

FEC Identification Number

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Memo Item

Memo Item

Memo Item

C

C

C
SCHEDULE C (FEC Form 3)

LOANS

PAGE OF

Use separate schedule(s) 

for each category of the 

Detailed Summary Page

NAME OF COMMITTEE (In Full)

SUBTOTALS This Period This Page (optional)....................................................................

TOTALS This Period (last page in this line only) ................................................................

FEC Schedule C (Form 3) (Revised 05/2016)

Carry outstanding balance only to LINE 3, Schedule D, for this line. If no Schedule D, carry forward to appropriate line of Summary.

Name of Employer

Occupation

List All Endorsers or Guarantors (if any) to Loan Source

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Original Amount of Loan Cumulative Payment To Date Balance Outstanding at Close of This Period

 Date Incurred Date Due Interest Rate Secured: 

 

 Yes No . % (apr)

Election: 

 Primary 

 General

 Other (specify) 

 LOAN SOURCE Full Name (Last, First, Middle Initial)

 Mailing Address

 City State ZIP Code

 1. Full Name (Last, First, Middle Initial)

 Mailing Address

 City State ZIP Code    , , .

Amount 

Guaranteed 

Outstanding:

Name of Employer

Occupation

 2. Full Name (Last, First, Middle Initial)

 Mailing Address

 City State ZIP Code    , , .

Amount 

Guaranteed 

Outstanding:

Name of Employer

Occupation

 3. Full Name (Last, First, Middle Initial)

 Mailing Address

 City State ZIP Code    , , . Amount 

Guaranteed 

Outstanding:

Name of Employer

Occupation

 4. Full Name (Last, First, Middle Initial)

 Mailing Address

 City State ZIP Code    , , . Amount 

Guaranteed 

Outstanding:

TERMS

FOR LINE NUMBER: 

(check only one) 13a

 13b

 M M / D D / Y Y Y Y M M / D D / Y Y Y Y

Memo Item

Personal Funds of the Candidate

(If none, enter 0)
E. Are any future contributions or future receipts of interest income, pledged as 

 collateral for the loan? No Yes If yes, specify: 

D. Are any of the following pledged as collateral for the loan: real estate, personal 

 property, goods, negotiable instruments, certificates of deposit, chattel papers, 

 stocks, accounts receivable, cash on deposit, or other similar traditional collateral?

 No Yes If yes, specify:

SCHEDULE C-1 (FEC Form 3)

LOANS AND LINES OF CREDIT FROM LENDING INSTITUTIONS

Federal Election Commission, Washington, D.C.

Supplementary for 

Information found on 

Page of Schedule C

FEC IDENTIFICATION NUMBER

C

NAME OF COMMITTEE (In Full)

 LENDING INSTITUTION (LENDER) 

 Full Name

 Mailing Address

 City State Zip Code

Amount of Loan

    , , .

FEC Schedule C-1 (Form 3) (Revised 05/2016)

Interest Rate (APR)

A. Has loan been restructured? No Yes If yes, date originally incurred

B. If line of credit, Total 

 Outstanding

 Amount of this Draw:    , , . Balance:    , , .

    , , .

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AUTHORIZED REPRESENTATIVE 

 Typed Name

 Signature Title

DATE

H. Attach a signed copy of the loan agreement.

I. TO BE SIGNED BY THE LENDING INSTITUTION:

 I. To the best of this institution’s knowledge, the terms of the loan and other information regarding the extension of the loan 

 are accurate as stated above.

 II. The loan was made on terms and conditions (including interest rate) no more favorable at the time than those imposed for 

 similar extensions of credit to other borrowers of comparable credit worthiness.

 III. This institution is aware of the requirement that a loan must be made on a basis which assures repayment, and has 

 complied with the requirements set forth at 11 CFR 100.82 and 100.142 in making this loan.

G. COMMITTEE TREASURER 

 Typed Name

 Signature

F. If neither of the types of collateral described above was pledged for this loan, or if the amount pledged does not equal or 

 exceed the loan amount, state the basis upon which this loan was made and the basis on which it assures repayment.

C. Are other parties secondarily liable for the debt incurred?

 No Yes (Endorsers and guarantors must be reported on Schedule C.)

Date Incurred or Established

Date Due

DATE

Date account established: 

Location of account:

Address:

City, State, Zip:

A depository account must be established pursuant 

to 11 CFR 100.82(e)(2) and 100.142(e)(2). 

 . %

What is the value of this collateral?

Does the lender have a perfected security

interest in it? No Yes

What is the estimated value?

 M M / D D / Y Y Y Y

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SCHEDULE D (FEC Form 3)

DEBTS AND OBLIGATIONS

Excluding Loans

(Use separate

schedule(s) 

for each 

numbered line)

NAME OF COMMITTEE (In Full)

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1) SUBTOTALS This Period This Page (optional) ...................................................................

2) TOTALS This Period (last page this line number only) ......................................................

3) TOTAL OUTSTANDING LOANS from Schedule C (last page only)..................................

4) ADD 2) and 3) and carry forward to appropriate line of Summary Page (last page only) 



A. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Mailing Address

City State Zip Code

Payment This Period

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FEC Schedule D (Form 3) (Revised 05/2016)

Outstanding Balance at Close of This Period

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



Outstanding Balance Beginning This Period

    , , .

Amount Incurred This Period

    , , .

Nature of Debt (Purpose):

B. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Mailing Address

City State Zip Code

Payment This Period

    , , .

Outstanding Balance at Close of This Period

    , , .

Outstanding Balance Beginning This Period

    , , .

Amount Incurred This Period

    , , .

Nature of Debt (Purpose):

C. Full Name (Last, First, Middle Initial) of Debtor or Creditor

Mailing Address

City State Zip Code

Payment This Period

    , , .

Outstanding Balance at Close of This Period

    , , .

Outstanding Balance Beginning This Period

    , , .

Amount Incurred This Period

    , , .

Nature of Debt (Purpose):

PAGE OF

FOR LINE NUMBER: 

(check only one) 9

 10
LINE DESCRIPTION

6(c) Net Contributions

7(c) Net Operating 

Expenditures

9 Debts and Obligations 

Owed TO the Committee

10 Debts and Obligations 

Owed BY the Committee

11(a)

Contributions from 

Individuals/Persons 

Other Than Political 

Committees

11(b)

Contributions from 

Political Party 

Committees

11(c) Contributions from Other 

Political Committees

11(d) Contributions from

the Candidate

11(e) Total Contributions

12 Transfers from Other 

Authorized Committees

13(a)

Loans Made or 

Guaranteed by

the Candidate

13(b) All Other Loans

13(c) Total Loans

14 Offsets to Operating 

Expenditures

FEC FORM 3Z (File with Form 3)

Part 1: CONSOLIDATION REPORT

Report Covering Period from:

to:

 M M / D D / Y Y Y Y

 M M / D D / Y Y Y Y

FEC Form 3Z (Revised 05/2016)

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LINE DESCRIPTION

15 Other Receipts

16 Total Receipts

17 Operating Expenditures

18 Transfers to Other 

Authorized Committees

19(a)

Repayments of Loans 

Made or Guaranteed

by Candidate

19(b) Other Loan Repayments

19(c) Total Loan Repayments

20(a) Refunds of Contributions 

to Individuals/Persons 

20(b)

Refunds of Contributions 

to Political Party 

Committees

20(c)

Refunds of Contributions 

to Other Political 

Committees

20(d) Total Contributions 

Refunds

21 Other Disbursements

22 Total Disbursements

23

Cash on Hand at

Beginning of 

Reporting Period

27 Cash on Hand at Close 

of Reporting Period    , , .

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NAME OF PRINCIPAL CAMPAIGN COMMITTEE

NAME OF COMMITTEE AUTHORIZED BY CANDIDATE

(Use Separate Page for Each Committtee)

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FEC FORM 3Z (File with Form 3)

Part 2: CONSOLIDATED TOTALS

FOR ALL AUTHORIZED COMMITTEES

Report Covering Period from:

to:

 M M / D D / Y Y Y Y

 M M / D D / Y Y Y Y

FEC Form 3Z (Revised 05/2016)

NAME OF PRINCIPAL CAMPAIGN COMMITTEE

For each line, add the amounts for all authorized committees and disclose the total on the appropriate line below.

LINE DESCRIPTION

6(c) Net Contributions

7(c) Net Operating 

Expenditures

9 Debts and Obligations 

Owed TO the Committee

10 Debts and Obligations 

Owed BY the Committee

11(a)

Contributions from 

Individuals/Persons 

Other Than Political 

Committees

11(b)

Contributions from 

Political Party 

Committees

11(c) Contributions from Other 

Political Committees

11(d) Contributions from

the Candidate

11(e) Total Contributions

12 Transfers from Other 

Authorized Committees

13(a)

Loans Made or 

Guaranteed by

the Candidate

13(b) All Other Loans

13(c) Total Loans

14 Offsets to Operating 

Expenditures    , , .

    , , .

    , , .

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LINE DESCRIPTION

15 Other Receipts

16 Total Receipts

17 Operating Expenditures

18 Transfers to Other 

Authorized Committees

19(a)

Repayments of Loans 

Made or Guaranteed

by Candidate

19(b) Other Loan Repayments

19(c) Total Loan Repayments

20(a) Refunds of Contributions 

to Individuals/Persons 

20(b)

Refunds of Contributions 

to Political Party 

Committees

20(c)

Refunds of Contributions 

to Other Political 

Committees

20(d) Total Contributions 

Refunds

21 Other Disbursements

22 Total Disbursements

23

Cash on Hand at

Beginning of 

Reporting Period

27 Cash on Hand at Close 

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