Marvin Mandel, Governor                           569

FORM 1

REPORT OR STATEMENT OF CAMPAIGN AND ELECTION
CONTRIBUTIONS AND EXPENDITURES

Registration No.

I,...................., treasurer for.............................................. do hereby

certify that the following is a complete and accurate statement of the

contributions received and expenses discharged by me as of..................

....................................,19.........

Balance on Hand (from previous report or opening bal-
ance, whichever is applicable)                                  $ ................

Receipts (from attached schedule)                              $ ................

Disbursements (from attached schedule)                     $ ................

Balance                                                                    $ ................

Surplus funds on hand upon filing of any report are deposited in

.................................., Account number...............................

(Name of Bank)

If this is a final report, surplus funds have been turned over to the

State Central Committee for the............................party or have been

distributed prorata to contributors on the basis of..............................

percentage.

Obligations remaining unpaid as of the date of this report are as
follows:

Amount                        Name and Address                        Purpose

(Signature of Treasurer)

If report is filed on behalf of a candidate or slate, the following
should be completed:

I, (We), the undersigned candidate(s), have examined the fore-
going report, and the attachments hereto, and certify that the same
are true to the best of our (my) knowledge, information and belief.

(Signature of Candidate)

Subscribed and sworn to (or affirmed) before me this........................

day of........................................, 19.........

(Notary public or other person authorized to administer oaths)

FORM 2
SCHEDULE OF RECEIPTS AND DISBURSEMENTS

Contributions and Expenditures of..........................................................

Receipt OR Disbursements:

(Strike out the incorrect word: DO NOT combine Receipts and
Disbursements on same sheet(s); use separate sheet(s) for each.
DO NOT combine Code Letters on same sheet. Use separate
sheet(s).)