FEC FORM 3X

Rev. 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. 

4. TYPE OF REPORT

(Choose One)

(a) Quarterly Reports:

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

PRE-Election

Report for the: Convention (12C) Special (12S)

30-Day

POST-Election General (30G) Runoff (30R) Special (30S)

Report for the:

(b) Monthly 

Report 

Due On:

Feb 20 (M2) May 20 (M5) Aug 20 (M8)

Mar 20 (M3) Jun 20 (M6) Sep 20 (M9)

Apr 20 (M4) Jul 20 (M7) Oct 20 (M10) Jan 31 (YE)

FEC 

FORM 3X

REPORT OF RECEIPTS 

AND DISBURSEMENTS

For Other Than An Authorized Committee

1. NAME OF 

COMMITTEE (in full)

ADDRESS (number and street)

Check if different 

than previously 

reported. (ACC)

TYPE OR PRINT

2. FEC IDENTIFICATION NUMBER ▼ CITY STATE ZIP CODE ▼ ▼ ▼

5. Covering Period through

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

April 15 

Quarterly Report (Q1)

July 15 

Quarterly Report (Q2)

October 15 

Quarterly Report (Q3)

January 31 

Year-End Report (YE)

July 31 Mid-Year 

Report (Non-election 

Year Only) (MY)

Termination Report 

(TER) in the 

Election on State of

in the 

Election on State of

Office Use Only

C

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3. IS THIS NEW AMENDED

REPORT (N) OR (A)

(c)

▼

Nov 20 (M11)

(Non-Election 

Year Only)

Dec 20 (M12)

(Non-Election 

Year Only)

Example: If typing, type 

over the lines.

(d)

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

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

Y Y Y Y

COLUMN B

Calendar Year-to-Date

COLUMN A

This Period

6. (a) Cash on Hand 

January 1, 

(b) Cash on Hand at 

Beginning of Reporting Period............

(c) Total Receipts (from Line 19) .............

(d) Subtotal (add Lines 6(b) and 

6(c) for Column A and Lines 

6(a) and 6(c) for Column B)...............

7. Total Disbursements (from Line 31)...........

8. Cash on Hand at Close of 

Reporting Period 

(subtract Line 7 from Line 6(d)).................

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 3X (Rev. 05/2016) Page 2

SUMMARY PAGE

OF RECEIPTS AND DISBURSEMENTS

This committee has qualified as a multicandidate committee. (see FEC FORM 1M)

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

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Report Covering the Period: From: To:

COLUMN B

Calendar Year-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 (add 

Lines 11(a)(i) and (ii).................

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

(c) Other Political Committees 

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

(d) Total Contributions (add Lines

11(a)(iii), (b), and (c)) (Carry 

Totals to Line 33, page 5) ..............

12. Transfers From Affiliated/Other 

Party Committees........................................

13. All Loans Received .....................................

14. Loan Repayments Received.......................

15. Offsets To Operating Expenditures 

(Refunds, Rebates, etc.) 

(Carry Totals to Line 37, page 5)...............

16. Refunds of Contributions Made 

to Federal Candidates and Other 

Political Committees....................................

17. Other Federal Receipts 

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

18. Transfers from Non-Federal and Levin Funds

(a) Non-Federal Account

(from Schedule H3).............................

(b) Levin Funds (from Schedule H5) .........

(c) Total Transfers (add 18(a) and 18(b))..

19. Total Receipts (add Lines 11(d), 

12, 13, 14, 15, 16, 17, and 18(c)).........

20. Total Federal Receipts 

(subtract Line 18(c) from Line 19) .........

DETAILED SUMMARY PAGE

of Receipts

Write or Type Committee Name

I. Receipts

FEC Form 3X (Rev. 05/2016) Page 3

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21. Operating Expenditures:

(a) Allocated Federal/Non-Federal 

Activity (from Schedule H4)

(i) Federal Share .............................

(ii) Non-Federal Share......................

(b) Other Federal Operating 

Expenditures .......................................

(c) Total Operating Expenditures

(add 21(a)(i), (a)(ii), and (b)) .............

22. Transfers to Affiliated/Other Party 

Committees.................................................

23. Contributions to 

Federal Candidates/Committees 

and Other Political Committees.................

24. Independent Expenditures 

(use Schedule E) ....................................... 25. Coordinated Party Expenditures 

(52 U.S.C. § 30116(d)) 

(use Schedule F)........................................

26. Loan Repayments Made............................

27. Loans Made................................................ 28. 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 28(a), (b), and (c))...........

29. Other Disbursements (Including 

Non-Federal Donations)...................................

30. Federal Election Activity (52 U.S.C. § 30101(20))

(a) Allocated Federal Election Activity

(from Schedule H6)

(i) Federal Share ................................

(ii) "Levin" Share.................................

(b) Federal Election Activity Paid

Entirely With Federal Funds ..............

(c) Total Federal Election Activity (add 

Lines 30(a)(i), 30(a)(ii) and 30(b)).....

31. Total Disbursements (add Lines 21(c), 22, 

23, 24, 25, 26, 27, 28(d), 29 and 30(c))..

32. Total Federal Disbursements 

(subtract Line 21(a)(ii) and Line 30(a)(ii)

from Line 31)..............................................

COLUMN B

Calendar Year-to-Date

COLUMN A

Total This Period

II. Disbursements

DETAILED SUMMARY PAGE

of Disbursements

FEC Form 3X (Rev. 05/2016) Page 4

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COLUMN B

Calendar Year-to-Date

COLUMN A

Total This Period

DETAILED SUMMARY PAGE

of Disbursements

FEC Form 3X (Rev. 05/2016) Page 5

III. Net Contributions/

Operating Expenditures

33. Total Contributions (other than loans) 

(from Line 11(d), page 3) ..........................

34. Total Contribution Refunds 

(from Line 28(d))........................................

35. Net Contributions (other than loans) 

(subtract Line 34 from Line 33) ................

36. Total Federal Operating Expenditures 

(add Line 21(a)(i) and Line 21(b)) .........

37. Offsets to Operating Expenditures 

(from Line 15, page 3)...............................

38. Net Operating Expenditures 

(subtract Line 37 from Line 36) ................

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Aggregate Year-to-Date ▼

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C

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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

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SCHEDULE A (FEC Form 3X)

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)

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

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

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Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Mailing Address

City State Zip Code

Receipt For:

Primary General

Other (specify)

Amount of Each Receipt this Period

A.

FEC Schedule A (Form 3X) Rev. 05/2016

Date of Receipt

Name of Employer (for Individual) Occupation (for Individual)

▼

FEC ID number of contributing

federal political committee.

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Mailing Address

City State Zip Code

Receipt For:

Primary General

Other (specify)

Amount of Each Receipt this Period

B.

Aggregate Year-to-Date ▼

Date of Receipt

▼

FEC ID number of contributing

federal political committee.

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Mailing Address

City State Zip Code

Receipt For:

Primary General

Other (specify)

Amount of Each Receipt this Period

C.

Aggregate Year-to-Date ▼

Date of Receipt

FEC ID number of contributing

federal political committee.

FOR LINE NUMBER: PAGE OF

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

Detailed Summary Page 11a 11b 11c 12

 13 14 15 16 17

Memo Item

Memo Item

Memo Item

Name of Employer (for Individual) Occupation (for Individual)

Name of Employer (for Individual) Occupation (for Individual)
SCHEDULE B (FEC Form 3X)

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)

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

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

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FEC Schedule B (Form 3X) Rev. 05/2016

Full Name (Last, First, Middle Initial)

Mailing Address

City State Zip Code

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

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

Use separate schedule(s) 

for each category of the 

Detailed Summary Page

FOR LINE NUMBER: PAGE OF

(check only one)

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)

Purpose of Disbursement

Candidate Name

Office Sought: House

Senate

President

State: District:

Category/

Type

Disbursement For:

Primary General

Other (specify) ▼

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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21b 22 23 26 27

28a 28b 28c 29 30b

Memo Item

Memo Item

Memo Item

C

C

C
SCHEDULE C (FEC Form 3X)

LOANS Use separate schedule(s) PAGE OF

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 3X) Rev. 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

Name of Employer

Occupation

Name of Employer

Occupation

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

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

Mailing Address

City State ZIP Code

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

Mailing Address

City State ZIP Code

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

Mailing Address

City State ZIP Code

Amount 

Guaranteed

Outstanding:

Amount 

Guaranteed

Outstanding:

Amount 

Guaranteed

Outstanding:

Amount 

Guaranteed

Outstanding:

TERMS

FOR LINE 13 OF FORM 3X

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

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Memo Item
C

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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

M M / D D / Y Y Y Y

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 3X)

LOANS AND LINES OF CREDIT FROM LENDING INSTITUTIONS

Federal Election Commission, Washington, D.C.

Supplementary for 

Information found on 

Page of Schedule C

NAME OF COMMITTEE (In Full) FEC IDENTIFICATION NUMBER

LENDING INSTITUTION (LENDER)

Full Name

Mailing Address

City State Zip Code

Amount of Loan

FEC Schedule C-1 (Form 3X) Rev. 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:

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?
SCHEDULE D (FEC Form 3X)

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) ▼

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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 3X) Rev. 05/2016

Outstanding Balance at Close of This Period

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Outstanding Balance Beginning This Period

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Nature of Debt (Purpose):

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

Mailing Address

City State Zip Code

Payment This Period

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Outstanding Balance at Close of This Period

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Outstanding Balance Beginning This Period

	 ▲	 ▲	 ▲ , , . Amount Incurred This Period

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Nature of Debt (Purpose):

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

Mailing Address

City State Zip Code

Payment This Period

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Outstanding Balance at Close of This Period

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Outstanding Balance Beginning This Period

	 ▲	 ▲	 ▲ , , . Amount Incurred This Period

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Nature of Debt (Purpose):

PAGE OF

FOR LINE NUMBER: 

(check only one) 9

 10
Date of Public Distribution/Dissemination

Amount

Date of Disbursement or Obligation

Date of Public Distribution/Dissemination

Amount

Date of Disbursement or Obligation

Memo Item

Memo Item

FEC Schedule E (Form 3X) Rev. 0/2016

Calendar Year-To-Date

Per Election for Office Sought

Calendar Year-To-Date

Per Election for Office Sought

NAME OF COMMITTEE (In Full)

SCHEDULE E (FEC Form 3X)

ITEMIZED INDEPENDENT EXPENDITURES

FOR LINE 24 OF FORM 3X

PAGE OF

C

FEC IDENTIFICATION NUMBER ▼

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Full Name of Payee

Mailing Address

City State Zip Code

Purpose of Expenditure

Name of Federal Candidate:

Full Name of Payee

Mailing Address

City State Zip Code

Purpose of Expenditure

Name of Federal Candidate:

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

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Disbursement For: Primary General

Other (specify)

Disbursement For: Primary General

Other (specify)

Category/

Type

Category/

Type

Office Sought: House District:

President Senate State:

 

Office Sought: House District:

President Senate State:

 

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Check if 24-hour report 48-hour report New report Amends report filed on M M / D D / Y Y Y Y

Support

Oppose

Support

Oppose

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

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

(a) TOTAL Independent Expenditures ........................................................................................

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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 (if the reporting entity is not a political 

party committee) any political party committee or its agent.

Date

Signature

M M / D D / Y Y Y Y
SCHEDULE F (FEC Form 3X)

ITEMIZED COORDINATED PARTY EXPENDITURES MADE BY 

POLITICAL PARTY COMMITTEES OR DESIGNATED AGENT(S) 

ON BEHALF OF CANDIDATES FOR FEDERAL OFFICE

 FOR LINE 25 OF FORM 3X

PAGE OF

NAME OF COMMITTEE (In Full)

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

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

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FEC Schedule F (Form 3X) Rev. 05/2016

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

Mailing Address

City State Zip Code

Amount

	 ▲	 ▲	 ▲ , , . Aggregate General Election 

Expenditure for this Candidate ▼

Date

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Name of Federal Candidate Supported Office Sought: House

Senate

Presidential

(To be used only by Political Committees in the General Election)

Has your committee been designated to make 

coordinated expenditures by a political party committee?

YES NO

If YES, name the designating committee:

Full Name of Subordinate Committee

Mailing Address

City State ZIP Code

Purpose of Expenditure

State:

District:

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

Mailing Address

City State Zip Code

Aggregate General Election 

Expenditure for this Candidate ▼

	 ▲	 ▲	 ▲ , , .

Name of Federal Candidate Supported Office Sought: House

Senate

Presidential

Purpose of Expenditure

State:

District:

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

Mailing Address

City State Zip Code

Aggregate General Election 

Expenditure for this Candidate ▼

	 ▲	 ▲	 ▲ , , .

Name of Federal Candidate Supported Office Sought: House

Senate

Presidential

Purpose of Expenditure

State:

District:

Category/

Type

Category/

Type

Category/

Type

M M / D D / Y Y Y Y

Amount

	 ▲	 ▲	 ▲ , , .

Date

M M / D D / Y Y Y Y

Amount

	 ▲	 ▲	 ▲ , , .

Date

M M / D D / Y Y Y Y

Memo Item

Memo Item

Memo Item
	 ▲. %

. %

A.

B. Separate Segregated Funds and Nonconnected Committees

Federal.......................................................................

Nonfederal .................................................................

This ratio applies to (check all that apply):

Administrative Generic Voter Drive Public Communications Referencing Party Only

State and Local Party Committees

Fixed Percentage (select one)

Presidential-Only Election Year (28% Federal)

Presidential and Senate Election Year (36% Federal)

Senate-Only Election Year (21% Federal)

Non-Presidential and Non-Senate Election Year (15% Federal)

SCHEDULE H1 (FEC Form 3X)

METHOD OF ALLOCATION FOR:

● ALLOCATED FEDERAL AND NONFEDERAL ADMINISTRATIVE, GENERIC VOTE

DRIVE AND EXEMPT ACTIVITY COSTS 

● ALLOCATED FEDERAL AND LEVIN FUNDS FEDERAL ELECTION ACTIVIT

EXPENSES (State, District and Local Party Committees Only)

● ALLOCATED PUBLIC COMMUNICATIONS THAT REFER TO ANY POLITICAL PART

(BUT NOT A CANDIDATE) (Separate Segregated Funds And Nonconnected Committees Only)

FEC Schedule H1 (Form 3X) Rev.05/2016 

NAME OF COMMITTEE (In Full)

USE ONLY ONE SECTION, A or B

Indicate ratio below
FEC Schedule H2 (Form 3X) Rev. 05/2016

ACTIVITY OR EVENT IDENTIFIER

ACTIVITY IS:

Fundraising Direct Candidate Support

CHECK IF THE RATIO IS:

New Revised Same as Previously Reported

SCHEDULE H2 (FEC Form 3X)

ALLOCATION RATIOS

NAME OF COMMITTEE (In Full)

RATIOS FOR ALLOCABLE FUNDRAISING EVENTS AND DIRECT CANDIDATE SUPPORT

ACTIVITIES APPEARING ON THIS REPORT.

Methods of allocation:

I. FUNDRAISING activities are allocated using the “funds received method” where the federal proportion of 

expenses must equal the federal proportion of monies raised.

II. Shared DIRECT CANDIDATE SUPPORT activities are allocated according to benefit expected to be derived, 

where the federal proportion of disbursements is based on the benefit derived by federal candidates from the activity. For PACs Only: Direct candidate support includes public communications or voter drives that refer to both 

federal and nonfederal candidates, regardless of whether there is a reference to a political party. Such expenses 

are allocated using a time/space method.

PAGE OF

FEDERAL % NONFEDERAL %

ACTIVITY OR EVENT IDENTIFIER

ACTIVITY IS:

Fundraising Direct Candidate Support

CHECK IF THE RATIO IS:

New Revised Same as Previously Reported

FEDERAL % NONFEDERAL %

ACTIVITY OR EVENT IDENTIFIER

ACTIVITY IS:

Fundraising Direct Candidate Support

CHECK IF THE RATIO IS:

New Revised Same as Previously Reported

FEDERAL % NONFEDERAL %

ACTIVITY OR EVENT IDENTIFIER

ACTIVITY IS:

Fundraising Direct Candidate Support

CHECK IF THE RATIO IS:

New Revised Same as Previously Reported

FEDERAL % NONFEDERAL %

ACTIVITY OR EVENT IDENTIFIER

ACTIVITY IS:

Fundraising Direct Candidate Support

CHECK IF THE RATIO IS:

New Revised Same as Previously Reported

FEDERAL % NONFEDERAL %

ACTIVITY OR EVENT IDENTIFIER

ACTIVITY IS:

Fundraising Direct Candidate Support

CHECK IF THE RATIO IS:

New Revised Same as Previously Reported

FEDERAL % NONFEDERAL %

	 ▲. % 	 ▲. %

	 ▲. % . %

	 ▲. % 	 ▲. %

	 ▲. % . %

	 ▲. % 	 ▲. %

	 ▲. % 	 ▲. %
	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

, , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

i) Total Administrative .............................................................................................................

ii) Generic Voter Drive .............................................................................................................

iii) Exempt Activities...................................................................................................................

iv) Direct Fundraising (List Activity or Event Identifier)

a)

b)

c) Total Amount Transferred For Direct Fundraising .............................................................

v) Direct Candidate Support (List Activity or Event Identifier)

a)

b)

c) Total Amount Transferred For Direct Candidate Support..................................................

vi) Public Communications Referring Only to Party (Made by PAC) ..................................

SCHEDULE H3 (FEC Form 3X)

TRANSFERS FROM NONFEDERAL ACCOUNTS FOR

ALLOCATED FEDERAL / NONFEDERAL ACTIVITY

NAME OF COMMITTEE (In Full)

PAGE OF

FOR LINE 18a OF FORM 3X

NAME OF ACCOUNT

	 ▲	 ▲	 ▲ , , .

DATE OF RECEIPT TOTAL AMOUNT TRANSFERRED

M M / D D / Y Y Y Y

FEC Schedule H3 (Form 3X) Rev. 05/2016

TOTALS FOR BREAKDOWN OF TRANSFER RECEIVED

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

TOTAL This Period (Administrative) ..........................................................

TOTAL This Period (Generic Voter Drive) .......................................................

TOTAL This Period (Exempt Activities)..................................................................

TOTAL This Period (Direct Fundraising).......................................................................

TOTAL This Period (Direct Candidate Support) ..................................................................

TOTAL This Period (Public Communications Referring Only to Party)......................................

TOTAL This Period (Total Amount Transferred)................................................................................

BREAKDOWN OF TRANSFER RECEIVED

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .
NAME OF COMMITTEE (In Full)

FEC Schedule H4 (Form 3X) Rev. 05/2016

SUBTOTAL of Allocated Federal and NonFederal Activity This Page 

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

FEDERAL SHARE NONFEDERAL SHARE TOTAL AMOUNT

TOTAL This Period (last page for each line only)(Federal share to 21(a)(i) and NonFederal share to 21(a)(ii))

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

FEDERAL SHARE TOTAL AMOUNT

+ =

	 ▲	 ▲	 ▲ , , .

NONFEDERAL SHARE

SCHEDULE H4 (FEC Form 3X)

DISBURSEMENTS FOR ALLOCATED 

FEDERAL/NONFEDERAL ACTIVITY

M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

Allocated Activity or Event:

Administrative Fundraising Exempt 

Voter Drive Direct Candidate Support

Public Comm (ref to party only) by PAC

Allocated Activity or Event Year-To-Date

Date

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

Mailing Address

City State Zip Code

Purpose of Disbursement:

Activity or Event Identifier:

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

FEDERAL SHARE + NONFEDERAL SHARE = TOTAL AMOUNT

Category/

Type

PAGE OF

FOR LINE 21a OF FORM 3X

M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

Allocated Activity or Event:

Administrative Fundraising Exempt 

Voter Drive Direct Candidate Support

Public Comm (ref to party only) by PAC

Allocated Activity or Event Year-To-Date

Date

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

Mailing Address

City State Zip Code

Purpose of Disbursement:

Activity or Event Identifier:

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

FEDERAL SHARE + NONFEDERAL SHARE = TOTAL AMOUNT

Category/

Type

M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

Allocated Activity or Event:

Administrative Fundraising Exempt 

Voter Drive Direct Candidate Support

Public Comm (ref to party only) by PAC

Allocated Activity or Event Year-To-Date

Date

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

Mailing Address

City State Zip Code

Purpose of Disbursement:

Activity or Event Identifier:

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

FEDERAL SHARE + NONFEDERAL SHARE = TOTAL AMOUNT

Category/

Type

Memo Item

Memo Item

Memo Item
	 ▲	 ▲	 ▲ , , . M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

, , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . M M / D D / Y Y Y Y

SCHEDULE H5 (FEC Form 3X)

NAME OF COMMITTEE (In Full)

PAGE OF

FOR LINE 18b OF FORM 3X

TRANSFERS OF LEVIN FUNDS RECEIVED FOR

ALLOCATED FEDERAL ELECTION ACTIVITY

(To be used by State, District and Local Party Committees Only)

NAME OF ACCOUNT DATE OF RECEIPT TOTAL AMOUNT TRANSFERRED

BREAKDOWN OF THIS TRANSFER

i) Voter Registration

Total Amount Transferred for Voter Registration......

ii) Voter ID

Total Amount Transferred for Voter ID ...............................

iii) GOTV

Total Amount Transferred for GOTV .................................................

iv) Generic Campaign Activity

Total Amount Transferred for Generic Campaign Activity ..............................

VOTER REGISTRATION

VOTER ID

GOTV

GENERIC CAMPAIGN ACTIVITY

FEC Schedule H5 (Form 3X) Rev. 05/2016

TOTALS FOR BREAKDOWN OF TRANSFER RECEIVED (Last Page Only)

TOTAL This Period (Voter Registration)..............................

TOTAL This Period (Voter ID) .......................................................

TOTAL This Period (GOTV).............................................................................

TOTAL This Period (Generic Campaign Activity).......................................................

TOTAL This Period (Total Amount of Transfers Received).................................................... 

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

NAME OF ACCOUNT DATE OF RECEIPT TOTAL AMOUNT TRANSFERRED

BREAKDOWN OF THIS TRANSFER

i) Voter Registration

Total Amount Transferred for Voter Registration......

ii) Voter ID

Total Amount Transferred for Voter ID ...............................

iii) GOTV

Total Amount Transferred for GOTV .................................................

iv) Generic Campaign Activity

Total Amount Transferred for Generic Campaign Activity ..............................

VOTER REGISTRATION

, , . VOTER ID

	 ▲	 ▲	 ▲ , , . GOTV

	 ▲	 ▲	 ▲ , , . GENERIC CAMPAIGN ACTIVITY

	 ▲	 ▲	 ▲ , , .
	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . , , . 	 ▲	 ▲	 ▲ , , .

SCHEDULE H6 (FEC Form 3X)

DISBURSEMENTS OF FEDERAL AND LEVIN FUNDS 

FOR ALLOCATED FEDERAL ELECTION ACTIVITY

(To be used by State, District and Local Party Committees Only) FOR LINE 30a OF FORM 3X

PAGE OF

NAME OF COMMITTEE (In Full)

	 ▲	 ▲	 ▲ , , . TOTAL This Period for the Levin Share

FEC Schedule H6 (Form 3X) Rev. 05/2016

SUBTOTAL of Shared Federal and Levin Activity This Page 

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

FEDERAL SHARE LEVIN SHARE TOTAL AMOUNT

TOTAL This Period (last page for each line only)(Federal share to 30(a)(i) and Levin share to 30(a)(ii))

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

FEDERAL SHARE TOTAL AMOUNT

LEVIN SHARE

+ =

Type of Allocated Activity or Event:

Voter Registration GOTV

Voter ID Generic Campaign

A. Full Name (Last, First, Middle Initial) / Full Organization Name

Mailing Address

City State Zip Code

Purpose of Disbursement

Allocated Activity or Event Year-To-Date

Date

FEDERAL SHARE + LEVIN SHARE = TOTAL AMOUNT

Category/

Type

Type of Allocated Activity or Event:

Voter Registration GOTV

Voter ID Generic Campaign

B. Full Name (Last, First, Middle Initial) / Full Organization Name

Mailing Address

City State Zip Code

Purpose of Disbursement

Allocated Activity or Event Year-To-Date

Date

FEDERAL SHARE + LEVIN SHARE = TOTAL AMOUNT

Category/

Type

Type of Allocated Activity or Event:

Voter Registration GOTV

Voter ID Generic Campaign

C. Full Name (Last, First, Middle Initial) / Full Organization Name

Mailing Address

City State Zip Code

Purpose of Disbursement

Allocated Activity or Event Year-To-Date

Date

, , . 	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

FEDERAL SHARE + LEVIN SHARE = TOTAL AMOUNT

Category/

Type

M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

Memo Item

Memo Item

Memo Item
	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . 	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , . , , .

SCHEDULE L (FEC Form 3X)

AGGREGATION PAGE: LEVIN FUNDS

NAME OF COMMITTEE (In Full)

NAME OF ACCOUNT

COLUMN B

YEAR-TO-DATE 

COLUMN A

TOTAL THIS PERIOD

FEC Schedule L (Form 3X) Rev. 05/2016

 1. RECEIPTS FROM PERSONS

(a) Itemized ..................................... (Use Schedule L–A)

(b) Unitemized ..................................

(c) Total.............................................

 2. OTHER RECEIPTS................................

 3. TOTAL RECEIPTS .................................

 (Add Lines 1c and 2)

 4. TRANSFERS TO FEDERAL OR 

ALLOCATION ACCOUNT 

(Use Schedule L–B)

(a) Voter Registration .......................

(b) Voter ID.......................................

(c) GOTV ..........................................

(d) Generic Campaign......................

(e) Total.............................................

 5. OTHER DISBURSEMENTS...................

 6. TOTAL DISBURSEMENTS .................... (Add Lines 4e and 5)

 7. BEGINNING CASH ON HAND.............. (for Column B, use cash as of January 1st)

 8. RECEIPTS.............................................. (from Line 3)

 9. SUBTOTAL ............................................ (Add Lines 7 and 8)

10. DISBURSEMENTS................................. (From Line 6)

11. ENDING CASH ON HAND..............................

(Subtract Line 10 From Line 9) ....................................
SCHEDULE L–A (FEC Form 3X)

ITEMIZED RECEIPTS OF LEVIN FUNDS

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)

PAGE OF

FOR LINE NUMBER: 

(check only one)

Use separate schedule(s) 

for each category of the 

Aggregation Page 1a 2

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Mailing Address

City State Zip Code

Amount of Each Receipt this Period

A.

Date of Receipt

Name of Employer (for Individual)

Occupation (for Individual)

Aggregate Year-to-Date

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Mailing Address

City State Zip Code

Amount of Each Receipt this Period

B.

Date of Receipt

Name of Employer (for Individual)

Occupation (for Individual)

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Mailing Address

City State Zip Code

Amount of Each Receipt this Period

C.

Date of Receipt

Name of Employer (for Individual)

Occupation (for Individual)

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

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

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

▼

Full Name of Individual (Last, First, Middle Initial) or Full Organization Name

Mailing Address

City State Zip Code

Amount of Each Receipt this Period

D.

Date of Receipt

Name of Employer (for Individual)

Occupation (for Individual)

	 ▲	 ▲	 ▲ , , .

	 ▲	 ▲	 ▲ , , .

M M / D D / Y Y Y Y

FEC Schedule L–A (Form 3X) Rev. 05/2016

Aggregate Year-to-Date

Aggregate Year-to-Date

Aggregate Year-to-Date

Memo Item

Memo Item

Memo Item

Memo Item
SCHEDULE L–B (FEC Form 3X)

ITEMIZED DISBURSEMENTS

OF LEVIN FUNDS

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)

Use separate schedule(s) 

for each category of the 

Aggregation Page

FOR LINE NUMBER: PAGE OF

(check only one) 

Full Name (Last, First, Middle Initial) / Full Organization Name

Mailing Address

City State Zip Code Amount of Each Disbursement this Period

	 ▲	 ▲	 ▲ , , .

A. Date of Disbursement

Purpose of Disbursement

M M / D D / Y Y Y Y

Full Name (Last, First, Middle Initial) / Full Organization Name

Mailing Address

City State Zip Code Amount of Each Disbursement this Period

	 ▲	 ▲	 ▲ , , .

B. Date of Disbursement

Purpose of Disbursement

M M / D D / Y Y Y Y

Full Name (Last, First, Middle Initial) / Full Organization Name

Mailing Address

City State Zip Code Amount of Each Disbursement this Period

	 ▲	 ▲	 ▲ , , .

C. Date of Disbursement

Purpose of Disbursement

M M / D D / Y Y Y Y

Full Name (Last, First, Middle Initial) / Full Organization Name

Mailing Address

City State Zip Code Amount of Each Disbursement this Period

	 ▲	 ▲	 ▲ , , .

D. Date of Disbursement

Purpose of Disbursement

M M / D D / Y Y Y Y

Full Name (Last, First, Middle Initial) / Full Organization Name

Mailing Address

City State Zip Code Amount of Each Disbursement this Period

	 ▲	 ▲	 ▲ , , .

E. Date of Disbursement

Purpose of Disbursement

M M / D D / Y Y Y Y

	 ▲	 ▲	 ▲ , , .

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

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

▼

FEC Schedule L–B (Form 3X) Rev. 05/2016

4a 4c 5

4b 4d

Memo Item

Memo Item

Memo Item

Memo Item

Memo Item