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OFFICE OF THE SUPERVISOR OF ELECTIONS 
 
STATEMENT OF ORGANIZATION 
 
 
Political Committee Registration re: 18 Virgin Islands Code 904: 
Each political committee which anticipates receiving contributions or making expenditures 
during the calendar year in an aggregate amount exceeding five hundred dollars ($500.00) shall 
file with the Supervisor of Elections a statement of organization. 
 
1. 
NAME AND ADDRESS OF COMMITTEE: 
 
_______________________________________________________________ 
 
_______________________________________________________________ 
 
________________________________________________________________ 
 
2. 
NAMES AND ADDRESS OF AFFILIATED OR CONNECTED  
 
 
 
ORGANIZATIONS: 
 
_________________________________________________________________ 
 
__________________________________________________________________ 
 
__________________________________________________________________ 
 
3. 
PURPOSE OF COMMITTEE: 
 
___________________________________________________________________ 
 
____________________________________________________________________ 
 
 
4. 
NAMES, ADDRESSES , CONTACT  NUMBERS , E-MAIL ADDRESSES AND 
TITLES OF PRINCIPAL OFFICERS OF THE COMMITTEE: 
 
____________________________________________________________________ 
 
____________________________________________________________________ 
 
____________________________________________________________________ 
 
 
 
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____________________________________________________________________ 
 
5. 
NAMES, ADDRESSES AND TITLES OF CUSTODIAN (S) OF ALL BOOKS AND 
 
 
 
 
 
 
ACCOUNTS: 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
6. 
NAMES, ADDRESSES, OFFICE SOUGHT OR OFFICE ASSISTING AND 
 
PARTY AFFILIATION OF EACH CANDIDATE THE COMMITTEE IS  
 
SUPPORTING OR OPPOSING, IF THE PURPOSE OF THE COMMITTEES IS 
 
TO OPPOSE A CANDIDATE: 
 
(a) SUPPORTING: 
     _____________________________________________________________________ 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
(b) OPPOSING: 
 
_____________________________________________________________________ 
 
________________________________________________________________________ 
 
________________________________________________________________________ 
 
7. 
BRIEF STATEMENT RELATIVE TO COMMITTEE: 
 
(a) 
IS THE COMMITTEE A CONTINUING ONE ? 
 
 
 
 
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________________________________________ 
 
(b) 
WHEN WAS THE COMMITTEE FORMED AND IS IT REGISTERED  
 
 
WITH THE OFFICE OF THE LT. GOVERNOR AND INTERNAL   
 
 
REVENUE SERVICE ? 
 
_______________________________________________________________ 
 
_______________________________________________________________ 
 
 
(c)  
WHEN IS THE COMMITTEE TO BE DISSOLVED ? 
 
______________________________________________ 
 
(d) 
IN THE EVENT OF DISSOLUTION OF THE COMMITTEE WHAT  
 
 
WILL BE THE METHOD OF DISPOSITION OF THE SURPLUS FUNDS?  
 
__________________________________________________________________ 
 
__________________________________________________________________ 
 
(e) 
PLEASE PROVIDE ANY OTHER INFORMATION PERTINENT TO THE 
 
 
ORGANIZATION OF THE COMMITTEE: 
 
__________________________________________________________________ 
 
__________________________________________________________________ 
 
__________________________________________________________________ 
 
8. 
 
LIST ALL BANKS AND ACCOUNT NUMBERS, SAFETY DEPOSIT         
 
 
BOXES, OR OTHER REPOSITORIES USED OR TO BE USED BY THE  
 
 
COMMITTEE: 
 
__________________________________________________________________ 
 
__________________________________________________________________ 
 
STATEMENT OF CHAIRMAN AND TREASURER OF THE COMMITTEE: 
 
We hereby jointly and individually declare that we have examined this 
Statement of Organization and to the best of our knowledge and belief the   
 
 
information provided herein is true and correct and complete. 
 
 
 
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Type or print name of Chairman 
 
 
Type or print name of Treasurer 
 
______________________________ 
 
________________________________ 
Signature of Chairman 
 
 
 
Signature of Treasurer 
 
______________________________ 
 
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Date 
 
 
 
 
 
 
Date 
 
SIGN
SIGN