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SEEC FORM CEP 16 Citizens’ Election Program-Supplemental Grant Request CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION Rev. 01/09 Page 1 of 2 CITIZENS’ ELECTION PROGRAM SUPPLEMENTAL GRANT REQUEST 8. CANDIDATE TELEPHONE NUMBER (Include Area Code) 9. CANDIDATE E-MAIL ADDRESS Statewide and General Assembly Candidates This form is intended for use by a candidate participating in the Citizens’ Election Program, their treasurer, deputy treasurer or their designated attorney. The participating candidate must have received a grant from the Program and the request must meet the conditions below. Section A. Identifying Information 2. NUMBER OFFICE SOUGHT 1. CANDIDATE ELECTION DATE 8. TELEPHONE (Include Area Code) DISTRICT NUMBER 9. CANDIDATE E-MAIL 3. ADDRESS (mm/dd/yyyy) 4. CANDIDATE COMMITTEE NAME 5. TITLE OF INDIVIDUAL MAKING REQUEST (Check One)  Participating Candidate  Treasurer  Deputy Treasurer  Attorney for Participating Candidate  Other Campaign Worker 6. NAME OF INDIVIDUAL MAKING REQUEST Prefix First MI Last 7. RESIDENCE ADDRESS 8. MAILING ADDRESS (if different) Street Address Address City State 9. TELEPHONE ( City State Zip Code 10. E-MAIL ADDRESS (Include Area Code) ) Zip Code Suffix — 11. NAME OF INDIVIDUAL OR COMMITTEE ALLEDGED TO HAVE FAILED TO REPORT (9-713) 12. OFFICE SOUGHT 13. DISTRICT NUMBER Conditions for Request: General Statutes section 9-713 Committee asserts that an opponent in their race received contributions, loans or other funds or made or incurred expenditures exceeding 100%, 125%, or 175% of the participating candidate’s applicable expenditure limit; OR General Statutes section 9-714 Committee asserts that an individual has made expenditures targeting the participating candidate’s defeat. Notice: A copy of this completed form will be provided to the opponent alleged to have failed to report excess receipts or expenditures, or to the individual who allegedly failed to report an independent expenditure targeting the defeat of the participating candidate. This form may not be used to allege any other violation of Connecticut Campaign Finance Laws. SEEC FORM CEP 16 Citizens’ Election Program-Supplemental Grant Request CONNECTICUT STATE ELECTIONS ENFORCEMENT COMMISSION Rev. 01/09 Page 2 of 2 8. CANDIDATE NUMBER (Include Area Code) 9. CANDIDATE Section B. TELEPHONE Affidavit for Supplemental Grant Request E-MAIL ADDRESS , am a resident of I, , Print Complainant’s Street Address Print Name of Complainant Town/City of , State of Print Town or City Name ; Print State & Zip Code And my Telephone Number is . Print Phone Number I hereby assert that the is entitled to a supplemental grant under the Print Name of Candidate Committee Citizens’ Election Program for the foregoing reasons: DESCRIBE FACTS AND ATTACH DOCUMENTARY SUPPORT, IF AVAILABLE, TO THIS FORM. Additional pages may be attached as needed. I solemnly swear (or affirm) that the above statement is true and complete to the best of my knowledge and belief. Dated this day of , 20___ at . Signed: Oath Administered By: Title: Note: This oath may be administered by anyone authorized by Section 1-24 of the Connecticut General Statutes, which includes notaries public, justices of the peace, town clerks and assistant town clerks, judges and clerks of any court, and attorneys who are Commissioner of the Superior Court of Connecticut. Notice: Making a false statement on this form may subject you to criminal penalties, including, but not limited to, imprisonment, a fine, or both.