Campaign Contribution Disclosure Report (CCDR)Group CCDR View Instructions Switch to Individual CCDR? Group Report Start Date of Statement (required) End Date of Statement (required) Round FirstSecondThird Political Committee's Name (required) Candidate or Candidates supported by Committee (required) (required) Office(s) Being Sought for Each Group Member (required) Non-LAUSD Email (required) Street Address (required) City (required) State (required) Zip Code (required) Phone Number (required) Attachment More than 10 line items of income, fundraisers, expenses, and/or contributions — or prefer to send a single document instead of using the form below? If so, attach your document here but include the grand total per section. Then, skip to the "I DECLARE..." section at the bottom. Document 5mb limit. DOC, DOCX, PDF, or XLS. If not providing an attachment, proceed with each section below. Income All contributions must come from UTLA Members, family, or friends. This requirement was not in place during the previous election. I. Carryover Funds Description Amount Total from the previous election that will be used in this election, if any II. Monetary Contributions For each row, include the name and relationship for individual contributor giving $25.00 or more. If an individual makes several donations, list the total amount of all their donations. Address and contact information must be available upon request from the Elections Committee. If candidates are part of a Political Committee and make contributions to the Political Committee, list each candidate’s name and the amount they contributed. If an individual candidate fundraises to pay for their contribution to their Political Committee, they must show those contributions on their individual Campaign Contribution Disclosure Report. Name + Relationship (UTLA Member, Family, or Friend) Amount III. Fundraisers Date of Event + Name of Host + Relationship (UTLA Member, Family, or Friend) Amount IV. Non-Monetary Contributions For each fair market value item is over $25.00: include a description of the contribution, name of contributor, and their relationship to the candidate or Political Committee. Allowed examples: paper goods, flyers, food or drink, photography, etc. Not allowed examples: sharing phone lists of UTLA members from another organization, sharing chapter chair or cluster phone lists. Description of Contribution + Name + Relationship (UTLA Member, Family, or Friend) Amount Expenses List all the expenses you incurred during your campaign, including any estimates of any bills yet received. Examples: the cost for a website or other electronic media, printing, postage and mailing costs, mileage to visit schools, reception costs for food, drinks, paper goods, entertainment, stickers, and buttons, etc. Item Name Amount Totals The following is automatically calculated based on the number(s) in the "amount" columns of the respective sections above. Total Income __________ Total Expenses __________ I certify that all contributions, except the carry over funds, came from UTLA members, family, or friends. I also declare the above assignment information to be true to the best of my knowledge. I also am aware that receipts may be asked to be provided to verify totals. (Required — check box below) Checking this box represents your e-signature I, __________, affirm under penalty of perjury that all of the information provided by me in this form is correct to the best of my knowledge. __________ Signature of Candidate __________ Date Signed This form goes to Princess M. Sykes of the UTLA Elections Committee, who can also be reached at psykes@utla.net or 3303 Wilshire Blvd., 10th floor, Los Angeles, CA 90010 or 1–213–637–5165.