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HomeMy WebLinkAboutCampaign Finance Records - Statement of organization - Responsible Leadership for Ocotillo - 1/15/20250 Initial Application © Amended Application I Date: 111312(}25 COMMITTEE TYPE (choose one): l 0 Candidate Committee Name (required): (first or last name & office) Candidate Information: Office Sought (choose one): STATE OF ARIZONA COMMITTEE ID NUMBER COMMITTEE STATEMENT (office use only) OF ORGANIZATION r n i Candidate's Name (required): ' Candidate's mailing address (required): Candidate's emai address (required): Candidates phone number (required): Candidate's website (if any): © County Office: IDDistrict (if applicable): _ OCityfTown Office: GDistrict (if applicable). 13 School Board Office: © District (if applicable): 17 Special District Board: GDistrict (if applicable): Election Cycle for Ofte Sought (year the election vdi take place) (required): 2025 Party Affiliation: 13 Democrat © Green O Libertarian (required for partisan offices) © Republican © Other. 0 Political Action Committee (PAC) Committee Name (required): Cancemed community Members for a Better t]cotillo-Dig id (if sponsored, must include sponsors name) Political Function (optional): W Contributions ❑ Candidate -Related Independent Expenditures (select any that apply) ❑ Ballot Measure Expenditures ® Recall Expenditures Sponsorship Information: (if applicable) Special Status (if applicable) ID Political Party Committee Name (required): (must include party affiliation) Jurisdiction: Special Status (if applicable) Sponsors name or nickname (required): Sponsor's mailing address (required): _ Sponsor's email address (required): r Sponsor's phone number (if any): Sponsor's website (if any): ❑ Separate Segregated Fund of a Corporation, LLC, Partnership, or Union ❑ Standing Committee (must also complete separate standing committee registration) ❑ Mega PAC (must provide proof of Mega PAC status to filing officer) (amended applications only) ® State Party (must include proof of qualification pursuant to A.R.S. § 16-801 or § 16-804) E1 County Party (must include proof of qualification pursuant to A.R.S. § 16-802 or § 16-804) 13 Legislative District Party (must include proof of organization pursuant to AR.S. § 16-823) 13 City or Town Party (must include proof of qualification pursuant to A.R.S. § 16-802 or § 16-804) 0 Standing Committee (must also complete separate standing committee registration) Arizona Secretary of State Revision 7/29/20221 E Initial Application STATE OF ARIZONA COMMITTEE ID NUMBER 13 Amended Application COMMITTEE STATEMENT (office use only) Date: 1119r2o25 OF ORGANIZATION oZ 5 - O t COMMITTEE INFORMATION: Contact Information: Committee's mailing address (required): 5838 W_ Northview Ave 85301 Committee's email address (required): homers4@msn.com Committee's phone number (if any): 6236953620 Committee's website (if any): Chairperson's Information: Chairperson's name (required): Derek M. Vukusich Treasurer's Information: Chairperson's physical address (required): 5838 W. Northview Ave 85301 Chairperson's mailing address (if different): Chairperson's email address (required): dvukusich@gmall.com Chairperson's phone number (required): 4803833776 Chairperson's employer (required): Phoenix Childrens Hospital Chairperson's occupation (required): Remote Endpoint Support Treasurer's name (required): Kathleen Collins Treasurer's physical address (required): 5820 W. Northview Ave85301 Treasurer's mailing address (if different): Treasurer's email address (required): Kmorocco@live.com Treasurer's phone number (required): 4809385593 Treasurer's employer (required): Retired Treasurer's occupation (required): Retired Bank or Financial institution. Bank name (required): Wells Fargo (do not list acct numbers) DECLARATION AND SIGNATURES: Additional bank name (if applicable): Additional bank name (if applicable): 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 receivelmake 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 taws 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: Date: 01/15/2025 Treasurer's signature: Date: 01/15/2025 Candidate's signature (if applicable): _ Date: Arizona Secretary of State Revision 7/29/2021