FEC Schedule 5 (REV. 09/2013)

5. COVERING PERIOD: FROM

THROUGH

6. TOTAL CONTRIBUTIONS...............................................................................................

7. TOTAL INDEPENDENT EXPENDITURES .....................................................................

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

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

TYPE OR PRINT NAME OF PERSON COMPLETING FORM SIGNATURE DATE

C

4. TYPE OF REPORT (check appropriate boxes):

24-Hour Report

48-Hour Report

(a) April 15 Quarterly Report

 July 15 Quarterly Report

 October 15 Quarterly Report

 January 31 Year-End Report

b) Is this Report an amendment? No Yes, it amends the report filed on

M M / D D / Y Y Y Y

M M / D D / Y Y Y Y

M M / D D / Y Y Y Y

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FEC FORM 5

REPORT OF INDEPENDENT EXPENDITURES MADE AND CONTRIBUTIONS RECEIVED

To Be Used by Persons (Other than Political Committees)

1. (a) Name of Individual, Organization or Corporation

(b) Address (number and street) check if different than previously reported

(c) City, State and ZIP Code

2. Occupation and Name of Employer (for Individual Filers Only) C

3. FEC Identification Number

Under penalty of perjury I certify that the independent expenditures reported herein were not made in cooperation, consultation, or concert with, or at the request or 

suggestion of, any candidate or authorized committee or agent of either, or any political party committee or its agent.
FEC Schedule 5 (Rev. 09/2013)

	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

C

Amount of Each Receipt this Period

C 	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

Amount of Each Receipt this Period

C 	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

SCHEDULE 5-A 

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 FILER (In Full)

	 ▲	 ▲	 ▲ , , .

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

TOTAL This Period (last page carry total to Line 6)........................................................................ ▼

▼

PAGE OF

A.

B.

C.

D.

Full Name (Last, First, Middle Initial)

Mailing Address

City State Zip Code

Date of Receipt

Name of Employer Occupation

FEC ID number of contributing

federal political committee.

Full Name (Last, First, Middle Initial)

Mailing Address

City State Zip Code

Date of Receipt

Name of Employer Occupation

FEC ID number of contributing

federal political committee.

Full Name (Last, First, Middle Initial)

Mailing Address

City State Zip Code

Amount of Each Receipt this Period

	 ▲	 ▲	 ▲ , , .

Date of Receipt

Name of Employer Occupation

FEC ID number of contributing

federal political committee. C

M M / D D / Y Y Y Y

Full Name (Last, First, Middle Initial)

Mailing Address

City State Zip Code

Amount of Each Receipt this Period

Date of Receipt

Name of Employer Occupation

FEC ID number of contributing

federal political committee.
FEC Schedule 5 (REV. 09/2013)

M M / D D / Y Y Y Y

NAME OF FILER (In Full)

SCHEDULE 5-E 

ITEMIZED INDEPENDENT EXPENDITURES FOR LINE 7 OF FORM 5

PAGE OF

(a) SUBTOTAL of Itemized Independent Expenditures.................................................................

(b) SUBTOTAL of Unitemized Independent Expenditures ............................................................

(c) TOTAL Independent Expenditures............................................................................................

▼

▼

▼

Date of Public Distribution/Dissemination

Amount

Full Name (Last, First, Middle Initial) of Payee

Mailing Address

City State Zip Code

Purpose of Expenditure

Name of Federal Candidate Supported or Opposed by Expenditure:

Disbursement For: Primary General

Other (specify)

Category/

Type

Office Sought: House

 Senate

 President

Check One: Support Oppose

State:

District:

▼

(carry total from last page forward to Line 7)

Date of Public Distribution/Dissemination

Amount

Full Name (Last, First, Middle Initial) of Payee

Mailing Address

City State Zip Code

Purpose of Expenditure

Name of Federal Candidate Supported or Opposed by Expenditure:

M M / D D / Y Y Y Y

Disbursement For: Primary General

Other (specify)

Category/

Type

Office Sought: House

 Senate

 President

Check One: Support Oppose

▼

Date of Public Distribution/Dissemination

Amount

Full Name (Last, First, Middle Initial) of Payee

Mailing Address

City State Zip Code

Purpose of Expenditure

Name of Federal Candidate Supported or Opposed by Expenditure:

M M / D D / Y Y Y Y

Disbursement For: Primary General

Other (specify)

Category/

Type

Office Sought: House

 Senate

 President

Check One: Support Oppose

▼

Calendar Year-To-Date Per Election

for Office Sought

Calendar Year-To-Date Per Election

for Office Sought

Calendar Year-To-Date Per Election

for Office Sought

State:

District:

State:

District:

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