57-L Communication Notification (LAUSD) · Email Address Phone Number Filer Information 57-L FORM Independent Expenditure Communication Notification (LAUSD) Revised May 2019 Los Angeles

Email Address Phone Number

Filer Information

57-LFORM Independent Expenditure

Communication Notification (LAUSD)

Revised May 2019 Los Angeles City Charter §§ 803(k), (r)(3), (s), (t) Page 1 of 4

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Name of Filer (Committee Name, if applicable)

Residential Address

Communication Information

I certify under penalty of perjury under the laws of the City of Los Angeles and the State of California that I am the filer or an agent of the filer, that the communication listed above was not behested by a candidate who benefitted from it, and that all the information reported through this form is true and complete.

_______________________________ _______________________________ ____________________Filer/Agent Name Filer/Agent Signature Date

_______________________________ _______________________________ ____________________Treasurer/Agent Name Treasurer/Agent Signature Date

Original Filing Amendment: Date of Signed Original ________________. Date of Last Amendment _________________.

ID Number (for committees)

A separate form is required for each communication. If the communication supports or opposes more than one candidate, separate forms must also be filed for each candidate, and the spending amounts reported on page 2 of this form must be apportioned among them. A copy of the communication must also be attached to this form. Los Angeles Charter § 803(s)(2) specifies the types of copies that must be filed. If the communication is not available when this form must be filed, the form must be amended to include the communication within one business day after the communication becomes available.

Certification

Format

Distribution

Type Purpose

Support or Oppose the following LAUSD candidate:

_____________________________________________________________________________________

Door Hanger Email Fax Flyer Mailing Print Ad Radio

Sign Sticker Telephone Television Text Message Web Video

Date First Distributed: ___________________________________________________ Number of Pieces: _______________________________

Independent Expenditure

Member Communication

Spending Information

57-LFORM Independent Expenditure

Communication Notification (LAUSD)

In the spaces below, identify the amount of spending per payee that was made or incurred for the candidateidentified on page 1. Use additional sheets if necessary.

Date(made or incurred)

Amount(made or incurred)

Payee(name and address)

Payee Services (all services provided by payee for reported amount)

Payee Vendors (name and address of each vendor used by payee for reported amount)

1. _______________________________________________________________________________________________________________

2. _______________________________________________________________________________________________________________

3. _______________________________________________________________________________________________________________

Date(made or incurred)

Amount(made or incurred)

Payee(name and address)

Payee Services (all services provided by payee for reported amount)

Payee Vendors (name and address of each vendor used by payee for reported amount)

1. _______________________________________________________________________________________________________________

2. _______________________________________________________________________________________________________________

3. _______________________________________________________________________________________________________________

Revised May 2019 Los Angeles City Charter §§ 803(k), (r)(3), (s), (t) Page 2 of 4

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Date(made or incurred)

Amount(made or incurred)

Payee(name and address)

Payee Services (all services provided by payee for reported amount)

Payee Vendors (name and address of each vendor used by payee for reported amount)

1. _______________________________________________________________________________________________________________

2. _______________________________________________________________________________________________________________

3. _______________________________________________________________________________________________________________

Persons making independent expenditure communications to support or oppose an LAUSD candidate are required to disclose all contributions of $100 or more that they made to any LAUSD candidate in the current calendar year. Please select one of the following options:

I did not make any reportable contributions.

I made the following reportable contributions (use additional sheets if necessary):

Contributions Made Page _____ of ______

57-LFORM Independent Expenditure

Communication Notification (LAUSD)

DateContributed

AmountContributed

Candidate or Committee Name

For candidates, identify office sought (including district number):

Name of Filer (Committee Name, if applicable) ID Number (for committees)

DateContributed

AmountContributed

Candidate or Committee Name

For candidates, identify office sought (including district number):

DateContributed

AmountContributed

Candidate or Committee Name

For candidates, identify office sought (including district number):

DateContributed

AmountContributed

Candidate or Committee Name

For candidates, identify office sought (including district number):

Revised May 2019 Los Angeles City Charter §§ 803(k), (r)(3), (s), (t) Page 3 of 4

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Committees must report information about contributions of $100 or more that they received since their most recent campaign statement or the first day of the calendar year, whichever is later. This does not apply to contributions earmarked for non-LAUSD purposes. Please select one of the following options:

I did not receive any reportable contributions.

I received the following reportable contributions (use additional sheets if necessary):

Contributions Received Page _____ of ______

57-LFORM Independent Expenditure

Communication Notification (LAUSD)

Name of Filer (Committee Name, if applicable) ID Number (for committees)

DateReceived

AmountReceived

Contributor’s Full Name

Contributor’s Address: _________________________________________________________________________________________________________

Contributor’s Employer/Occupation: ___________________________________________________________________________________________

DateReceived

AmountReceived

Contributor’s Full Name

Contributor’s Address: _________________________________________________________________________________________________________

Contributor’s Employer/Occupation: ___________________________________________________________________________________________

DateReceived

AmountReceived

Contributor’s Full Name

Contributor’s Address: _________________________________________________________________________________________________________

Contributor’s Employer/Occupation: ___________________________________________________________________________________________

DateReceived

AmountReceived

Contributor’s Full Name

Contributor’s Address: _________________________________________________________________________________________________________

Contributor’s Employer/Occupation: ________________________________________________________________________________________

Revised May 2019 Los Angeles City Charter §§ 803(k), (r)(3), (s), (t) Page 4 of 4

ethics.lacity.org