Financial Disclosure Report Form If your list of donors exceeds the number of spaces on this form list the total as a single donation and itemize on a separate document, or if you'd like a PDF version instead, please contact us. Please review the Election Manual: X. Other Campaign Rules H. Candidates shall not seek or receive local, state or national affiliate financial support or any other form of support for his or her candidacy from vendors, UTLA staff, politicians or outside organizations and persons who stand to benefit financially or otherwise from their relationship with UTLA. K. Financial Reports Candidates for all offices, and political committees formed by candidates or in which candidates are active participants, shall, at the conclusion of the election, file one financial report with the Elections Committee on a form approved by the Committee. The report shall detail all expenditures, income and sources of income for a specific balloting in the election.report shall be due on or before 5:00 p.m. the day upon which the ballots are counted. Each candidate must sign the following affirmation “I affirm that all of the information provided by me in this form is correct to the best of my knowledge.” Financial reports pertaining to subsequent balloting shall be on file on or before 5:00 p.m. the day upon which the ballots are counted. The financial statements of candidates and committees shall be printed in summary form in the next United Teacher issue after their due date, with a notice that originals are on file for inspection. A candidate who has not filed a financial report shall not be permitted to assume the office to which that candidate has been elected unless and until the report is filed. UTLA ELECTIONS COMMITTEE Start Date of Statement (required) End Date of Statement (required) Name of Candidate or Committee (required) Office or Offices Being Sought (required) Non-LAUSD Email (required) Street Address (required) City (required) State (required) Zip Code (required) Phone Number (required) Attachment Prefer to send a single document instead of using the form below? If so, attach your document here and skip to "I DECLARE..." section at the bottom. If not, proceed with the Income section below. Document 5mb limit. DOC, DOCX, PDF, or XLS. Income I. Monetary Contributions A. Itemized Full name of individual or committee contributor if the amount is over $50.00 Name Amount B. Non-itemized If the amount is $50.00 or less Name Amount Total non-itemized monetary contributions Sub-total of monetary contributions: __________ II. Non-monetary Contributions A. Itemized Full name of individual or committee contributor if the amount is over $50.00 Name Amount B. Non-itemized If the amount is $50.00 or less Name Amount Total non-itemized non-monetary contributions Sub-total of non-monetary contributions: __________ III. Loans Received Itemized Full name of individual or committee contributor/organization if the amount is over $50.00 Name Amount Sub-total of loans: __________ Expenses Income Amount Telephone Mailings (postage, office supplies, etc.) Receptions (food, paper goods, entertainment, etc.) Misc. Office and Meeting Supplies Not Reported Food for Volunteers Estimate of Bills Not Received Website or Other Media Room or Equipment Rentals Mileage to Visit Schools Loans Repaid Other (please specify) Totals Total Income __________ Total Expenses __________ I declare the above assignment information true to the best of my knowledge. (required) 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 Tara Thomas of the UTLA Elections Committee, who can also be reached at email@example.com or 3303 Wilshire Blvd., 10th floor, Los Angeles, CA 90010 or 1–213–637–5165.