Campaign Finance &
Public Disclosure Board
Suite 190 . Centennial Office Building . 658 Cedar Street . St. Paul MN 55155-1603 . 651/296-5148 . 800/657-3889
e-mail at: [email protected].
AFFIDAVIT AND REPORT OF
INDEPENDENT EXPENDITURES
Filing Instructions
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This affidavit and report must be completed and filed with a Report of Receipts and Expenditures covering
the period in which the independent expenditure(s) was made.
This statement may be filed by facsimile. Fax number: 651/296-1722 or 800/357-4114.
Do not use pencil or red ink.
All information on this report is public information.
Address questions to Board staff at 651/282-6894; 800/657-3889.
Affidavit
State of Minnesota
County of
)
) ss
)
(Please print or type)
Name of Committee, Fund, or Party Unit
Reg. #
Street address
City/state/zip
Telephone # including area code
Fax # including area code
I, the undersigned treasurer, being first duly sworn, states as follows:
1. The committee or fund listed above made independent expenditures and is reporting them on the Report
through
.
of Receipts and Expenditures for the period
2. The independent expenditures made by the committee or fund were not made with the authorization or
expressed or implied consent of, or in cooperation or in concert with, or at the request or suggestion of any
candidate, any candidate’s principal campaign committee or agent.
Signature of treasurer
Date signed
Notarization
Sworn to and subscribed before me this
day of
, 20
.
Notary Seal
Signature of notary public or other officer empowered to administer oaths
This document is available in alternative formats to individuals with disabilities by calling 651/296-5148; 800/657-3889; or through
the Minnesota Relay Service at 800/627-3529.
Affidavit_Report_Indpndt_Expen.doc (08/06)
Reporting Instructions
Use this schedule to itemize independent expenditures made by your committee or fund.
You must itemize independent expenditures that in aggregate total more than $100 to any one entity. When
multiple transactions occur with one vendor, show the vendor’s name once and list all transactions with that vendor
separately under the vendor’s name.
Entries must be in alphabetical order.
For itemized expenditures you must disclose the:
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date the expenditure was made by your committee or fund;
name of the vendor, including third party payees;
vendor’s full address (street, city, state, and zip code);
name, office sought, and district number of affected candidate;
whether expenditure is for or against candidate;
specific purpose of expenditure; and
amount of expenditure(s);
Do not itemize expenditures that total $100 or less to one entity.
For Non-itemized transactions:
You must disclose the total of all expenditures
expenditures/disbursements” line at the bottom of the form.
of
$100
or
less
on
the
“Non-itemized
Itemization of Independent Expenditures
Make photocopies of this page if additional space is needed.
Nume and full address of
For
Against
vendor paid. Name of
Date
candidate candidate
candidate affected.
Candidate office/district
Specific purpose
of expenditure
(i.e.bill board,
campaign ad)
2 Unpaid
bills
1 Cash
3 Total
0.00
0.00
0.00
0.00
0.00
Non-itemized expenditures/disbursements
$
$
$ 0.00
$ 0.00
$ 0.00
TOTALS $ 0.00
Totals in Columns one, two and three must be brought forward to the Cash Balance Summary page of the accompanying Report of
Receipts and Expenditures and disclosed on the Independent Expenditure line in the proper column.
It is unlawful to use this information for commercial purposes.
Affidavit_Report_Indpndt_Expen.doc (08/06)