UTLA Elections

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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

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.