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Statementof Dissolution

Effec{iveJanuary1, 2010,thls fonn mustbe filed ebcfonically by


mostdate commltts. Eftctiw Jarruary1,2011,thls brm must Cdtnt.#
be tlhd ffionlsally by musl hral oommlttees.Pleaecchock
withthe Boardto rce ffyou are rqutrcd !o frleit eteolronlcally,
Independentexponditureconmrittresmustfrlethis $om @r$fredDsb of D'Eoolutfon
el*{ronblV-

g(, - 7'l€6
Code

ufl{EtfTroFt€:
The Slatesnentof [Xssolu0onmustbe filed wlthinfilrty (30] daysof cofiipldsn of all ths btlqving:
1. Al debB, loensand obllgatonshaw beenpaidor bans{aned;
2. Ail €m@nfrmds IEl€ beg| sDent
3. All ocrnpalgnproportyEoldortranofiEned(condldatc only);and
/+. A final reportdiedcing ail ransadiono doslng the commfrteehas beenfllo.

For eialecandldatcrand dde PACs,a final bankstnfterrerilrunf tre filed sfln rhe SUHneil d DlssOMm tn'a s€sr F
pogsibleif |he benksfteftefiEnt
is nd avallabled the frne he Stafiem€rilof Ossoldim is fttl.

"6ttta-trtu
glgnftrc d Cardidate or Trqis{r€r (lt Gheilror

FOR INSTNUCTIONS, SEE BACK OF FOR'II

BoardAddrws:510E 12!'Srtet€ils 1A' Des Molnes,lA5O319 FaxNumben51+.2814073

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