Yavapai County Elections

Yavapai County Elections
1015 Fair St, RM 228
Prescott, AZ 86305
(928) 771-3248 x8
yavapaivotes.gov
elections@yavapaiaz.gov
Yavapai County Elections

Committee Statement of Organization
Date*

MonthDayYear
Date
Choose One:*

Initial ApplicationAmended Statement of Organization
Amended Date

MonthDayYear
Date
Committee Type:*

CandidatePolitical Action Committee (PAC)Political Party
Committee Name*
Election Cycle for Office Sought (year election will take place, required)*
Candidate's Name*

First NameLast Name
Party Affiliation (required for partisan offices)*

DemocratLibertarianRepublicanOther
If Other, fill in the blank.*
Candidate's Mailing Adress*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Candidate's Email*
example@example.com
Candidate's Phone Number*
Please enter a valid phone number.
Candidate's Website
Office Sought*

AssessorAttorneyBOS - District 1BOS - District 2BOS - District 3BOS - District 4BOS - District 5Clerk of Superior CourtConstableJustice of the PeaceRecorderSchool SuperintendentSpecial District Board (Fire, Water, Sanitation, Hospital, Road, etc.)SheriffSuperior Court JudgeTreasurer
District / Division Name*
Committee Name (if sponsored, must include sponsor's name)*
Political Function (Choose any that apply)*

Ballot Measure ExpendituresCandidate-Related Independent ExpendituresContributionsRecall Expenditures
Sponsorship Information
Sponsor's Name or Nickname*
Sponsor's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sponsor's Email*
example@example.com
Sponsor's Phone Number*
Please enter a valid phone number.
Sponsor's Website
Special Status: choose one*

Speparate Segregated Fund of a Corporation, LLC, Partnership, or UnionStanding Committee (Must also complete separate standing committee registration)Mega PAC (must provide proof of Mega PAC status to filing officer, amended applications only)
Party Name*
Jurisdiction*

County Party (must include proof of qualification pursuant to A.R.S.§ 16-802 or § 16-804)Legislative District Party (must include proof of organizationpursuant to A.R.S. § 16-823)
Special Status

Standing Committee (must also complete separate standing committee registration)
Committee Information
Committee's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Committee's Email*
example@example.com
Committee Phone Number*
Please enter a valid phone number.
Committee's Website
Chairperson's Information
Chairperson's Name*

First NameLast Name
Chairperson's Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the Chairperson have a mailing address different than their physical address?*

YESNO
Chairperson's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Chairperson's Email*
example@example.com
Chairperson's Phone Number*
Please enter a valid phone number.
Chairperson's Employer*
Chairperson's Occupation*
Treasurer's Information
Treasurer's Name*

First NameLast Name
Treasurer's Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the Treasurer have a mailing address different than their Physical Address?*

YESNO
Treasurer's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Treasurer's Email*
example@example.com
Treasurer's Phone Number*
Please enter a valid phone number.
Treasurer's Employer*
Treasurer's Occupation*
Banking Information
Bank Name*
Additional Bank Name (if Applicable)
Additional Bank Name (If Applicable)
DECLARATION AND SIGNATURES

I declare under penalty of perjury that the foregoing information is true and correct. I further declare that I: (1) consent to serve as chairperson or
treasurer of the committee named herein, if applicable; (2) designate the above-named committee as my official candidate committee and authorize it
to receive/make contributions/expenditures on my behalf, if applicable; (3) have read the Secretary of State's campaign finance and reporting guide;
(4) agree to comply with Arizona election law, including campaign finance laws codified at A.R.S. §§ 16-901 to 16-938; and (5) agree to accept all
notifications and legal service of process for campaign finance purposes via the email address(es) provided herein.
Chairperson's Signature*

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Date*

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Date
Treasurer's Signature*

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Date*

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Candidate's Signature*

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Date*

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Date
Should be Empty:

Sponsorship Information

Committee Information

Chairperson's Information

Treasurer's Information

Banking Information