r»-

'

!' '

•-.- ^•'TCpM/cl'rj
V.v i-/!• /.« or-',

r

STATEMENT OF
ORGANIZATION

FEC
FORM 1

Office Use Only

1.

NAME OF
COMMITTEE (in full)

Example: If typing, type
over the lines.

(Check if name
is changed)

1

12FE4M5

IP.UT, ,V,

i i i i i i i i
I

I I I I

I

I

I

I

I

I

I

I

I

I

I

I

I

I

I

I

I

l

I

I

I

I

I

I

I

I

i i i i i i i i i i

ADDRESS (number and

(Check If address
is changed)

I

LSiUiIiTi£i

i i

i i i i i i i i i i i i i i i i i i i i i i i i

IV.AI
CITY

STATE

ZIP CODE

COMMITTEE'S E-MAIL ADDRESS (Please provide only one e-mail address)

Q

MI

(Check If address
is changed)

o

I'tinr? lOiftpiUifriVierfci&ilii ifi6iii.,iOinfl
I

i i
i i i i i

l

COMMITTEE'S WEB PAGE ADDRESS (URL)

NY
0

(Check If address
is changed)

§7
«~l .

2.

\

I

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

i i 1

DATE

3. FEC IDENTIFICATION NUMBER

4.

IS THIS STATEMENT

NEW (N)

OR

AMENDED (A)

/ certify that I have examined this Statement and to the best of my knowledge and belief it is true, correct and complete.

TL .
Type or Print Name of Treasurer S\±LJC\_af\

JL
M«r

Signature of Treasurer

NOTE: Submission of false, erroneous, or incomplete information may subject the person signing this Statement to the penalties of 2 U.S.C. §437g.
ANY CHANGE IN INFORMATION SHOULD BE REPORTED WITHIN 10 DAYS.

L

Office
Use
Only

^raTEtecfcmcSm^1*'1'
Toll Free 600-4244530
Local 202-694-1100

PE

C FQRM 1
(Revised 02/2009)

1
— 1

 I I

r
5.

FEC Form 1 (Revised 02/2009)

~i

Page 2

TYPE OF COMMITTEE

Candidate Committee:
This committee Is a principal campaign committee. (Complete the candidate information below.)

(a)

(b)

yj

This committee is an authorized committee, and is NOT a principal campaign committee. (Complete the candidate
information below.)

Name of
Candidate

l i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i . i l
0,,^
Sought:

Candidate
Party Affiliation

State

House

Senate

L

President
District

This committee supports/opposes only one candidate, and is NOT an authorized committee.

(c)

Name
_ ~ of.
Candidate

I i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i
I i i i i i •
i i i i i
i i i i i i
i i i i i i

ii Ii ii ii ii

Party Committee:
(d)

0

(National, State
or subordinate) committee of the

This committee is a

(Democratic,
Republican, etc.) Party.

Political Action Committee (PAC):
(e)

 J

This committee is a separate segregated fund. (Identify connected organization on line 6.) Its connected organization is a:
UJ

Corporation

 J

Corporation w/o Capital Stock

&JJ

Labor Organization

Q

Membership Organization

0

Trade Association

Q

Cooperative

Q
(f)

SSjl
rAS

In addition, this committee is a Lobbyist/Registrant PAC.

This committee supports/opposes more than one Federal candidate, and is NOT a separate segregated fund or party
committee, (i.e., nonconnected committee)
[]

In addition, this committee is a Lobbyist/Registrant PAC.

 J

In addition, this committee is a Leadership PAC. (Identify sponsor on line 6.)

Joint Fundraislng Representative:

(g)

This committee collects contributions, pays fundraislng expenses and disburses net proceeds for two or more political
committees/organizations, at least one of which is an authorized committee of a federal-candidate.

(h)

This committee collects contributions, pays fundraislng expenses and disburses net proceeds for two or more political
committees/organizations, none of which is an authorized committee of a federal candidate.

Committees Participating in Joint Fundraiser
1.

I I I I I I I I

I I I I I I I I

I I I I I I I FEC ID numberfC

2.

I I I I I I I I

I I I I I I I I

I I I I I I I FEC ID numberfc

3-

I I I I

I I

I I I I

I I

I I

I I I

 

      FEC ID numberJC
iFECIDnumber

L

J

 r

FEC Form 1 (Revised 02/2009)

Page 3

Write or Type Committee Name

"P.A V^k P,«i} PAC
6.

Name of Any Connected Organization, Affiliated Committee, Joint Fundralslng Representative, or Leadership PAC Sponsor

I

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Mailing Address

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
I I I I I I I I I I I I I I I I I I I
CITY
CO

I . I
STATE

I . . ,

. l - l . i . l

ZIP CODE

Relationship: f] Connected Organization PfAffiliated Committee fl Joint Fundraising Representative fl Leadership PAC Sponsor

CD
hO
m

7.

M\

Custodian of Records: Identify by name, address (phone number - optional) and position of the person In possession of committee

books and records.

CD
Full Name

CD

IJjrM-J-ini^i

•

CD

Zi-,

Mailing Address

. Ai*RiTirti 0\^t

11 I

/^

/*

ir-)i/)iM?.Ti£?irO

T3L *D f\ A r\

i

f ~T

!<*' \U\ ifci • i \ Q \ * * V \ n V \ iSi I i-

, 1 ,

IF.A.L.I.S.
Title or Position

CITY

i

8.

. i

i

STATE

......

ZIP CODE

Telephone number

Treasurer: List the name and address (phone number - optional) of the treasurer of the committee; and the name and address of
any designated agent (e.g., assistant treasurer).

i/V^rr,H,u^ .H.yt,AP.T.o.Mi
Mailing Address

 g(.  /  6/i iCi/i

iG>iXi6i/»Pi

i

t S i / i/ i i i i i i i i i i i i i i i i i

J

_l_

IV/\I
CITY

STATE

J

I

ZIP CODE

Tftte or Position

tT,R£,

L

ft^U^gH

i

.........

I

J

 r

FEC Form 1 (Revised 02/2009)

Full Name of
Designated

,

Agent

I

Mailing Address

Page 4

,
i

i

i

i

i

i

i

i

i

i

i

i

i

i

I i i i i i

i

i

i

i

i

i

i

i

i

i

i

i

i i i t

i

i

i

i

i

i

i

i

i

i

i

i

I

i i i i I

I i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i I
I i i i i i i i i i i i i i i i i i I
CITY

I i I
STATE

I i i i i l~l i i i I
ZIP CODE

Title or Position
I i i i i i i i i i i i i i i i i i i i I

9.

Telephone number

I i i I -1 i i I -1 i i i I

g)

Banks or Other Depositories: List all banks or other depositories in which the committee deposits funds, holds accounts, rents
safety deposit boxes or maintains funds.

Q

Name of Bank, Depository, etc.

Ni
w

I

CD

tiri

n"'

Mailing Address

hfl
O

/ < A /\ M

n

i

n

IfcOiQiOi
iDiUi^iJ) . , i i i i i i i I
HfitJiUiUi i/Vi«i
i / V i « i iM/iliLnLiJ-iA/Ai^iK^iNfri
iWJiULiJ-iffc/niSilSiWi <Nfa-i iOiUt</d>i.

I i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i I

P

, . i i I

vf- ...
CITY

[Mi
STATE

. i i - i i
L3.2iaiMI-l
ZIP CODE

Name of Bank, Depository, etc.

I i i i i i
. . Mailing Address

I i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i I

I i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i I
I i i i i i i i i i i i i i i i i i I
CITY

L

I i I
STATE

I i i i i I-1 i i i I
ZIP CODE

J

 Federal Election Commission
ENVELOPE REPLACEMENT PAGE FOR INCOMING DOCUMENTS
i
The FEC added this page to the end of this filing to indicate how it was received, j
Date of Receipt

;

Hand Delivered
Postmarked
USPS First Class Mail
Postmarked (R/Cj
USPS Registered/Certified
Postmarked
USPS Priority Mail
Delivery Confirmation™ or Signature Confirmation™ Label
Postmarked
USPS Express Mail

Postmark Illegible

No Postmark
Shipping Date
Overnight Delivery Service (Specify):
Next Business Day Delivery
Date of Receipt ;
Received from House Records & Registration Office
Date of Receipt i
Received from Senate Public Records Office
Date of Receipt
Received from Electronic Filing Office
Date of Receipt or Postmarked
Other (Specify):

PREPARER
(3/2005)

DATE PREPARED