Candidates

Financial Disclosure Report Form

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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, __________, 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 tthomas@utla.net or 3303 Wilshire Blvd., 10th floor, Los Angeles, CA 90010 or 1–213–637–5165.