Form 8872

(Rev. October 2014)

Department of the Treasury 

Internal Revenue Service

Political Organization 

Report of Contributions and Expenditures

▶ Information about Form 8872 and its instructions is available at www.irs.gov/form8872.

▶ 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 

Inspection

A For the period beginning , 20 and ending , 20

B Check applicable boxes: Initial report Change of address Amended report Final report

1 Name of organization Employer identification number 

2 Mailing address (P.O. Box or number, street, and room or suite number)

City or town, state or province, country, and ZIP or foreign postal code

3 Email address of organization 4 Date organization was formed

5a Name of custodian of records 5b Custodian's address

6a Name of contact person 6b Contact person's address

7 Business address of organization (if different from mailing address shown above). Number, street, and room or suite number

City or town, state or province, country, and ZIP or foreign postal code

8 Type of report (check only one box)

a First quarterly report (due by April 15)

b Second quarterly report (due by July 15)

c Third quarterly report (due by October 15)

d Year-end report (due by January 31)

e Mid-year report (Non-election year only–due by July 31)

f Monthly 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)

g Pre-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:

h Post-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) . . . . . . . . . . . 9

10 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 instructions. Cat. No. 30406G Form 8872 (Rev. 10-2014) 
Form 8872 (Rev. 10-2014)

Schedule A Itemized 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 code Name of contributor's employer

Contributor's occupation

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Contributor's name, mailing address and ZIP code Name of contributor's employer

Contributor's occupation

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Contributor's name, mailing address and ZIP code Name of contributor's employer

Contributor's occupation

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Contributor's name, mailing address and ZIP code Name of contributor's employer

Contributor's occupation

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Contributor's name, mailing address and ZIP code

Contributor's occupation

Name of contributor's employer

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Contributor's name, mailing address and ZIP code Name of contributor's employer

Contributor's occupation

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Contributor's name, mailing address and ZIP code Name of contributor's employer

Contributor's occupation

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Contributor's name, mailing address and ZIP code Name of contributor's employer

Contributor's occupation

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Contributor's name, mailing address and ZIP code Name of contributor's employer

Contributor's occupation

Aggregate contributions

year-to-date . . . . . ▶ $

Amount of contribution

$

Date of contribution

Subtotal of contributions reported on this page only. Enter here and also include this amount in the total on line 9 of 

Form 8872 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶ $

Open to Public Inspection Form 8872 (Rev. 10-2014)
Form 8872 (Rev. 10-2014)

Schedule B Itemized 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 code Name of recipient's employer

Recipient's occupation

Amount of expenditure

$

Date of expenditure

Purpose of expenditure 

Recipient's name, mailing address and ZIP code Name of recipient's employer

Recipient's occupation

Amount of expenditure

$

Date of expenditure

Purpose of expenditure 

Recipient's name, mailing address and ZIP code Name of recipient's employer

Recipient's occupation

Amount of expenditure

$

Date of expenditure

Purpose of expenditure 

Recipient's name, mailing address and ZIP code Name of recipient's employer

Recipient's occupation

Amount of expenditure

$

Date of expenditure

Purpose of expenditure 

Recipient's name, mailing address and ZIP code Name of recipient's employer

Recipient's occupation

Amount of expenditure

$

Date of expenditure

Purpose of expenditure 

Recipient's name, mailing address and ZIP code Name of recipient's employer

Recipient's occupation

Amount of expenditure

$

Date of expenditure

Purpose 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 8872 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶ $

Open to Public Inspection Form 8872 (Rev. 10-2014)