Disclosure System

Organization Information *

Enter information for the organization responsible for the major contribution.

Organization Name *

Mailing Address

Address *

City *

State *

ZIP *

Organization Phone Number *

Organization Email Address *

Responsible Officer Name *

Responsible Officer Position *

Form of Organization *

Purpose of Organization *

Does the organization have a tax-exempt status with the Internal Revenue Service? *

Yes

No

Under what section of the tax code does the organization claim this exemption? *

For example “Section 501(c)(3)” or “Section 501(c)(4)”

Campaign Finance Jurisdictions *

List all jurisdictions in which this organization files campaign finance reports.

Source of Funds *

List the five largest sources of funds received by the organization beginning 6 months prior to the first contribution made to the ballot question committee. Do not include sources that paid funds to the organization in the ordinary course of the organization’s regular business or sources that earmarked their funds for a specific purpose unrelated to the ballot question.

Source of Funds 1 *

Source of Funds 2 Optional

Source of Funds 3 Optional

Source of Funds 4 Optional

Source of Funds 5 Optional

Has this organization received contributions, in whole or in part, to influence a Maine ballot question? *

Yes

No, I certify that this organization has not received any contributions to influence a Maine ballot question.

Contributions Received *

List any contributions received, in whole or in part, for the purpose of initiating or influencing a ballot question in Maine.

Contribution Date *

Contribution Source *

Contribution Description *

Amount *

Recipient Ballot Question Committee *

Some of the information below has been automatically entered based on information provided by the BQC that notified you of this filing requirement. You may edit this automatically entered information to correct any mistakes or omissions.

Ballot Question Committee *

Name of Recipient Ballot Question Committee *

Address of Recipient Ballot Question Committee *

Amount of First Contribution to Ballot Question Committee *

Total Amount Given to Ballot Question Committee *

Contributions to Ballot Question Committee *