Please Print Form and Submit Original Signed form to the Town Clerk's Office following electronic submission.

A Committee Registration form must be filed with the Town Clerk prior to taking any contributions for a candidate or an issue, or making any expenditures on behalf of a candidate or an issue. Formation of a committee requires that a separate bank account be opened in the name of the Committee, and that all contributions, contributions in kind, loans, and expenditures be reported on the forms provided by the Town Clerk.

TODAY'S DATE:*

COMMITTEE NAME: *

Registered Agent: *

Telephone Number: *

Email Address:

Committee Type:*

Candidate Committee

Issue Committee

Committee's Bank:*

Type of Filing:*

Regularly Scheduled Filing Amended Report

Termination Report (MUST have a Zero balance)

Amends report filed on:

REPORTING PERIOD

Beginning Date:*

Ending Date:*

DO NOT ENTER "$" SIGNS

Beginning Balance:*

Contributions:*

Expenditures:*

Ending Balance:*

I hereby certify that, to the best of my knowledge and belief, all contributions received and all expenditures made during this reporting period are accurately reflected in this report.

Registered Agent Name:*

Registered agent's signature: ____________________________________________ Date: _______________

If Applicable

Candidate Name:

Canididate's signature: __________________________________________________ Date: _______________

Detailed Report of CONTRIBUTIONS

(Fill out additional forms if needed - indicate "page 2" after Committee Name)

DO NOT ENTER "$" SIGNS

Date Accepted (xx/xx/xxxx):

Amount:

Name (Last, First):

Address:

City:

State:

Zip:

Date Accepted (xx/xx/xxxx):

Amount:

Name (Last, First):

Address:

City:

State:

Zip:

Date Accepted (xx/xx/xxxx):

Amount:

Name (Last, First):

Address:

City:

State:

Zip:

Date Accepted (xx/xx/xxxx):

Amount:

Name (Last, First):

Address:

City:

State:

Zip:

Date Accepted (xx/xx/xxxx):

Amount:

Name (Last, First):

Address:

City:

State:

Zip:

Detailed Report of EXPENDITURES

DO NOT ENTER "$" SIGNS

Date Incurred:

Amount:

Payable to:

Purpose of Expenditure:

Date Incurred:

Amount:

Payable to:

Purpose of Expenditure:

Date Incurred:

Amount:

Payable to:

Purpose of Expenditure:

Date Incurred:

Amount:

Payable to:

Purpose of Expenditure:

Detailed Report of CONTRIBUTIONS IN KIND

DO NOT ENTER "$" SIGNS

Date Accepted:

Estimated Value:

Received from:

Address:

City:

State:

Zip:

Nature of Contribution:

Date Accepted:

Estimated Value:

Received from:

Address:

City:

State:

Zip:

Nature of Contribution:

Date Accepted:

Estimated Value:

Received from:

Address:

City:

State:

Zip:

Nature of Contribution:

Date Accepted:

Estimated Value:

Received from:

Address:

City:

State:

Zip:

Nature of Contribution:

Detailed Report of LOANS

DO NOT ENTER "$" SIGNS

Date Accepted:

Amount:

Loan received from:

Address:

City:

State:

Zip:

Purpose of Loan:

Date Accepted:

Amount:

Loan received from:

Address:

City:

State:

Zip:

Purpose of Loan:

NOTE: After hitting "Submit and Print", use Internet print function to print page, then MUST HIT "CONTINUE" to submit electronically.

Submit Original Signed form to Town Clerk after submitting electronically