STATE OF MARYLAND PETITION FUND REPORT
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1 Page 1 of Pages STATE OF MARYLAND PETITION FUND REPORT Statewide Referendum Petition to: The Secretary of State Public Local Law Referendum to: The Secretary of State Charter Board Petition to: County Commissioners Charter Amendment Petition to: Mayor of the City of Baltimore or President of the County Council Local Referendum Petition to: Appropriate County Authority Entity Name Mailing Address Report Period: From: To: (date) (date) Type of Report: First Petition Follow-up Petition No. Final Report - Surplus funds were distributed to. Bank Name and Branch Location Account Number Bank Account Balance Summary of Receipts and Disbursements 1. Cash Balance Beginning of period $ 2. Receipts from Schedule 1: Column D $ 3. Total Cash Available (line 1 plus line 2) $ 4. Disbursements from Schedule 2: Column E $ 5. Cash Balance - End of Period (line 3 minus line 4) $ 6. Total Outstanding Debts from Schedule 3: Column C $ Under penalty of perjury, I declare that I have examined this report, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. Principal Officer of Committee Date Treasurer Date OFFICE USE ONLY Report received:, Time Received by:
2 General Instructions This report is to be completed by the treasurer of any entity established to promote the success of a petition under either Article XI-A or Article XVI of the Maryland Constitution, and is to be filed as required by Election Law, 7-105(c) of the Annotated Code of Maryland; or it is to be completed and filed in connection with a local law referendum as required by the appropriate charter and/or laws. The report must include: 1. Petition Fund Report Summary Page - Mandatory 2. Schedule 1 - Receipts Not required if there are no receipts to report. 3. Schedule 2 - Disbursements - Not required if there are no disbursements to report. 4. Schedule 3 - Outstanding Debts - Not required if there are no outstanding debts to report. Summary Page Instructions Where Filed a) For Charter Board Petitions, with the County Commissioners. b) For Charter Amendment Petitions, with the Mayor of the City of Baltimore or the President of the County Council. c) For Local Referendum Petitions, with the county authority designated by charted and/or local law. Entity Name- Indicate complete name of the entity. Report Period - Indicate beginning and ending dates for transactions covered by the report. Type of Report PETITION -Indicate whether the petition accompanying the report is a first or follow-up FINAL - The report must indicate the disposition of all surplus funds. petition. Cash Balance - Beginning of period On first report, this amount should be "ZERO". On subsequent reports, this amount should equal the "Cash Balance - End of period" shown on the preceding report. Receipts from Schedule 1 - Grand total of all pages of Schedule 1, Column D. Total Cash Available - Add "Cash Balance- Beginning of Period" and "Total Receipts" Disbursements from Schedule 2 - Grand total of all pages of Schedule 2, Column E. Cash Balance - End of Period Subtract "Total Disbursements" from "Total Cash Available". This amount should equal the Committee's bank balance and the beginning balance for the next report. Bank Information - List the Bank Name, Branch, Account Number and the bank account balance as of the end transaction date. Total Outstanding Debts from Schedule 3 - Grand total of all pages of Schedule 3, Column C. Page 1 of Pages - When report is complete, assemble and number all pages consecutively. Signatures - Treasurer and Principal Officer of Committee MUST sign under penalty of perjury.
3 Page of Pages SCHEDULE 1 - RECEIPTS Entity Name: Report Period: From: To: (date) (date) (A) (B) (C) (C) (D) Date Received Complete Name and Principal Residence Address of Payer Receipt Code (see back) Cash or Check Amount Received Page Total This
4 INSTRUCTIONS SCHEDULE 1 - RECEIPTS This form is used to report all funds received from any source. All funds should be deposited in the Entity's bank account. 1. Enter Entity Name and Report Period. For all reports after first report, account for all transactions since last report. 2. Column A - Enter DATE RECEIVED by Treasurer. 3. Column B - Record complete NAME AND PRINCIPAL RESIDENCE ADDRESS OF PAYER. 4. Column C - Identify TYPE OF RECEIPT, using the following CODES: C = Contributions L = Loans IK = In-Kind Contributions Identify Receipt by Cash or Check in the second Column C. 5. Column D - Report the AMOUNT received. If a single amount is received for more than one purpose, i.e., part as a contribution and part as a loan, report each type of receipt as a separate item. 6. Total all amounts in Column D at the bottom of the page (and if more than one page is used, enter a grand total at the bottom of the last page). 7. DO NOT NUMBER PAGES until report is completed.
5 Page of Pages SCHEDULE 2 - DISBURSEMENTS Entity Name Report Period: From: To: (date) (date) (A) (B) (C) (D) (E) Date Check # Payee and Address Code Amount Page Total This
6 ALL DISBURSEMENTS MUST BE BY CHECK. INSTRUCTIONS SCHEDULE NO. 2 - DISBURSEMENTS 1. Enter Entity Name and Report Period. For all reports after first report, account for all transactions since last report. 2. Column A - DATE of disbursement. 3. Column B - Report all disbursements in CHECK NO. sequence. Indicate any void checks. 4. Column C - PAYEE AND ADDRESS - Provide complete name and address of payee. 5. Column D - Identify all disbursements by reference to ONE of the following CODES: Code A B C D E F G Expense Compensation for Personnel (include salaries) Field Expenses Broadcasting Publicity, Literature, etc. Office Expenses Repayment of Loans Miscellaneous 6. Column E - Report the AMOUNT of the disbursement. 7. Total all amounts in Column E at the bottom of the page (and if more than one page is used, enter a grand total at the bottom of the last page). 8. DO NOT NUMBER PAGES until report is completed.
7 9. Page of Pages SCHEDULE 3 - OUTSTANDING DEBTS Entity Name: Report End Date - Debts as of, 20 (A) (B) (C) Name and Address Description of Debt Amount (Loan, unpaid bill, etc.) Total This Page
8 INSTRUCTIONS - SCHEDULE NO. 3 - OUTSTANDING DEBTS All Debts, including Loans, which are UNPAID as of the end date of this report must be recorded on SCHEDULE NO Enter Entity Name and Report End Date. 2. Column A - Record complete NAME AND ADDRESS of person or firm to whom debt is owed. 3. Column B - Describe DEBT by type. 4. Column C - Report AMOUNT of debt. 5. TOTAL all amounts in Column C at the bottom of the page (and if more than one page is used, enter a grand total at the bottom of the last page). 6. DO NOT NUMBER PAGES until report is completed. Dod/forms/ revised 2001
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