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

This form is for the use by a candidate who has not received any contributions, but has made expenditures of personal funds.

TODAY'S DATE (xx/xx/xxxx):*

CANDIDATE NAME: *

Address: *

City:*

State:*

Zip:*

REPORTING PERIOD:

Beginning Date (xx/xx/xxxx): *

Ending Date (xx/xx/xxxx): *

Detailed Report of EXPENDITURES

Date Expended (xx/xx/xxxx):

Amount (Do NOT enter "$" sign):

Payable to:

Address:

City:

State:

Zip:

Purpose of Expense:

Date Expended (xx/xx/xxxx):

Amount (Do NOT enter "$" sign):

Payable to:

Address:

City:

State:

Zip:

Purpose of Expense:

Date Expended (xx/xx/xxxx):

Amount (Do NOT enter "$" sign):

Payable to:

Address:

City:

State:

Zip:

Purpose of Expense:

I certify to the best of my knowledge this Statement of Expenditures is true and correct.

Canididate's signature: _________________________________________________ Date: ___________________

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