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<br />PC 10 Statement of Independent Expenditures <br />please type or print legibly in black ink; list only one entry per line <br />J, name of individual, organization or committee use full name <br /> <br />rev 1/06 <br /> <br />committee ID number <br /> <br />residence address street, city, state, zip code <br /> <br />day phone number <br /> <br />o Primary 20_ <br /> <br />o General 20_ <br /> <br />o other: <br /> <br />01 st pre-election <br />o Post-election <br /> <br />o 2nd pre-election 0 1 st Supplement to the 2nd pre <br />o 20_Sept. Suppl. <br /> <br />o 2nd Supplement to the 2nd pre <br /> <br /> <br />*address includes city, or county if no city, and state <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />. <br /> <br />$ <br /> <br />$ <br /> <br /> <br />for office use only <br /> <br />I hereby certify the above listed expenditures were made for the candidates <br />or measures specified. <br /> <br />signature <br /> <br />date signed <br /> <br />PC 10 <br /> <br />see instructions on back and in Campaign Finance Manual <br />