CandidatesFinancial Disclosure Report Form If you'd like a PDF version instead, please contact us. 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) 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 firstname.lastname@example.org or 3303 Wilshire Blvd., 10th floor, Los Angeles, CA 90010 or 1–213–637–5165.