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SCHEDULE A (FEC Form 4) Use separate schedule(s) 

FOR LINE NUMBER: 

(check only one) 

PAGE O F 

ITEMIZED RECEIPTS for each category of the 

Detailed Summary Page 13 14a 15 16a

 16b 17a 18a 19a 

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) 

Full Name (Last, First, Middle Initial) 

A. Date of Receipt

Mailing Address 

City State Zip Code 

Amount of Each Receipt this Period 

M M / D D / Y Y Y Y 

FEC ID number of contributing 

federal political committee. C ▲, , . ▲ ▲

Name of Employer Occupation 

Receipt For: Aggregate Year-to-Date ▼

Primary General 

Other (specify) ▼ ▲, , . ▲ ▲

Full Name (Last, First, Middle Initial) 

B. Date of Receipt

Mailing Address 

City State Zip Code 

Amount of Each Receipt this Period 

M M / D D / Y Y Y Y 

FEC ID number of contributing 

federal political committee. C , , . ▲▲▲

Name of Employer Occupation 

Receipt For: Aggregate Year-to-Date ▼

Primary General 

Other (specify) ▼ , , . ▲▲▲

Full Name (Last, First, Middle Initial) 

C. Date of Receipt

Mailing Address 

City State Zip Code 

Amount of Each Receipt this Period 

M M / D D / Y Y Y Y 

FEC ID number of contributing 

federal political committee. C , , . ▲▲▲

Name of Employer Occupation 

Receipt For: Aggregate Year-to-Date ▼

Primary General 

Other (specify) ▼ , , . ▲▲▲

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

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

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FEC Schedule A (Form 4) (Revised 1/01) 

FE1AN056.PDF 
▼ ▼

SCHEDULE B (FEC Form 4) FOR LINE NUMBER: PAGE OF 

Use separate schedule(s) (check only one) for each category of the 

Detailed Summary Page 

ITEMIZED DISBURSEMENTS 

21a 22 23a 23b 24a 

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) 

Full Name (Last, First, Middle Initial) 

A. Date of Disbursement 

Mailing Address 

M M / D D / Y Y Y Y 

City State Zip Code Amount of Each Disbursement this Period 

Purpose of Disbursement ▲, , . ▲ ▲

Candidate Name Category/ 

Type 

Office Sought: House 

Senate 

President 

Disbursement For: 

Primary General 

Other (specify) ▼

State: District: 

Full Name (Last, First, Middle Initial) 

B. Date of Disbursement 

Mailing Address 

M M / D D / Y Y Y Y 

City State Zip Code Amount of Each Disbursement this Period 

Purpose of Disbursement , , .▲▲▲

Candidate Name Category/ 

Type 

Office Sought: House 

Senate 

President 

Disbursement For: 

Primary General 

Other (specify) ▼

State: District:
 

Full Name (Last, First, Middle Initial)
 

C. Date of Disbursement 

Mailing Address 

M M / D D / Y Y Y Y 

City State Zip Code Amount of Each Disbursement this Period 

Purpose of Disbursement , , .▲▲▲

Candidate Name Category/ 

Type 

Office Sought: House 

Senate 

President 

Disbursement For: 

Primary General 

Other (specify) ▼

State: District: 

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

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

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FEC Schedule B (Form 4) (Revised 1/01) 

FE1AN056.PDF 
▼ ▼

SCHEDULE C (FEC Form 4) 

LOANS Use separate schedule(s) PAGE O F 

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) ............................................................. 

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 

▲, , . ▲ ▲

▲, , . ▲ ▲

▲, , . ▲ ▲ ▲, , . ▲ ▲ ▲, , . ▲ ▲

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 16a OF FORM 4 

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

FEC Schedule C (Form 4) (Revised 1/01) 

FE1AN056.PDF 
Supplementary for 

Information found on 

Page of Schedule C 

SCHEDULE C-1 (FEC Form 4) 

LOANS AND LINES OF CREDIT FROM LENDING 

INSTITUTIONS Federal Election Commission, Washington, D.C.

NAME OF COMMITTEE (In Full) FEC IDENTIFICATION NUMBER 

C 

LENDING INSTITUTION (LENDER) Amount of Loan Interest Rate (APR) 

Full Name 

▲ ▲ , , .	 ▲ ▲. %

Mailing Address 

Date Incurred or Established 

M M / D D / Y Y Y Y 

M M / D D / Y Y Y Y 

City	 State Zip Code Date Due 

M M / D D / 

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

Y Y Y Y 

B. If line of credit, Total 

▲ ▲, ▲. Outstanding 

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

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

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

D. Are any of the following pledged as collateral for the loan: real estate, personal What is the value of this collateral? 

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:
 

Does the lender have a perfected security
 

interest in it?
 No
 

▲ ▲ , , . ▲

Yes 

E. Are any future contributions or future receipts of interest income, pledged as What is the estimated value? 

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

▲ ▲ , , . ▲

A depository account must be established pursuant Location of account: 

to 11 CFR 100.7(b)(11)(i)(B) and 100.8(b)(12)(i)(B). 

Date account established: Address: 

M M / D D / Y Y Y Y 

City, State, Zip: 

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.

G. COMMITTEE TREASURER DATE
 

Typed Name

Signature

M M / D D / Y Y Y Y 

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 for the at 11 CFR 100.7(b)(11) and 100.8(b)(12) in making this loan.

AUTHORIZED REPRESENTATIVE DATE
 

Typed Name
 

Signature
 Title 

FEC Schedule C-1 (Form 4) (Revised 1/01) 

FE1AN056.PDF 

M M / D D / Y Y Y Y 
▼ ▼ ▼ ▼

SCHEDULE D (FEC Form 4) PAGE OF (Use separate 

schedule(s) FOR LINE NUMBER: DEBTS AND OBLIGATIONS (check only one) 9

numbered line) 

for each 

10 

NAME OF COMMITTEE (In Full) 

Excluding Loans 

A. Full Name (Last, First, Middle Initial) of Debtor or Creditor Nature of Debt (Purpose): 

Mailing Address 

City State Zip Code 

Outstanding Balance Beginning This Period 

▲, , . ▲ ▲

Amount Incurred This Period Payment This Period Outstanding Balance at Close of This Period 

▲, , . ▲ ▲ ▲, , . ▲ ▲ ▲, , . ▲ ▲

B. Full Name (Last, First, Middle Initial) of Debtor or Creditor Nature of Debt (Purpose): 

Mailing Address 

City State Zip Code 

Outstanding Balance Beginning This Period 

▲, , . ▲ ▲

Amount Incurred This Period Payment This Period Outstanding Balance at Close of This Period 

▲, , . ▲ ▲ ▲, , . ▲ ▲ ▲, , . ▲ ▲

C. Nature of Debt (Purpose): Full Name (Last, First, Middle Initial) of Debtor or Creditor 

Mailing Address 

City State Zip Code 

Outstanding Balance Beginning This Period 

▲, , . ▲ ▲

Amount Incurred This Period Payment This Period Outstanding Balance at Close of This Period 

▲, , . ▲ ▲ ▲, , . ▲ ▲ ▲, , . ▲ ▲

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) .................................
 

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▲, , . ▲ ▲

▲, , . ▲ ▲

▲, , . ▲ ▲

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

FEC Schedule D (Form 4) (Revised 1/01) 

FE1AN056.PDF