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STATEMENT OF ORGANIZATION
FEC FORM1
(See instructions)
1.
NAME OF COMMITTEE (In 1ull)
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(Check if name is changed)
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STATE A.
ZIP CODE A.
COMMITTEE'S E-MAIL ADDRESS i
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2.
DATE
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3.
FEC IDENTIFICATION NUMBER
4.
IS THIS STATEMENT
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NEW(N)
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AMENDED (A)
i certify that I have examined this Statement ana to the best of my knowledge and belief it is true, correct and complete Type or Print Name of Treasurer
Signature of Treasurer
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NOTE: Submission of raise, erroneous, or incomplete Information may subject the person signing this Statement to we penalties of 2 U.S.C. S437g. ANY CHANGE IN INFORMATION SHOULD BE REPORTED WITHIN 10 DAYS
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For further information contact: Federal Election Commission
(Only
Toll Free 800-424-3530 Local 202-694-1100
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FEO-ornM (Revised 02/2003)
Page 2
6. TYPE OF COMMITTEE (Check One) (a)
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(b)
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This committee is a principal campaign committee. (Complete the candidate information below.)
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This committee Is an authorized committee, and is NOT a principal campaign committee. (Complete the candidate information below.)
Name of Candidate
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House
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Senale
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President
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This committee supports/opposes only one candidate, and is NOT an authorized committee.
Name of Candidate
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Candidate Party Affiliation
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(National. State p"-"1 (or subordinate) committee of the »HrtiItef.h I --
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This committee Is a separate segregated fund
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(Democratic, Republican,etc.) Party.
This committee supports/opposes more than one Federal candidate, and is NOT a separate segregated fund or party committee. 6.
Name of Any Connected Organization or Affiliated Committee
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Mailing Address
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ZIP CODE A
Relationship Type of Connected Organization: LJ | I
Corporation Membership Organization
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Corporation w/o Capital Stock
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Labor Organization
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Trade Association
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Cooperative
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FECFomH (Revised 02/2003)
Write or Type Committee Name HISPANICS FOR A CONSERVATIVE AMERICA 7.
Custodian of Records: Identify by name, address, (phone number - optional), and position of the person In possession of Committee books and records. SCOTT B MACKENZIE i i _i_ i i I i i i i
Full Name
1155 -1STH STREET, NW
Mailing Address
SUITE 410 WASHINGTON Title or Position V
CITY A
DC
20005
ZIP CODE A
STATEA
DEPUTY TREASURER
-
703
868
1778
Telephone number
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Treasurer List the name and address (phone, number •- optional) of the treasurer of the committee: and the name and address of any designated agent (e.g., assistant treasurer).
Full Nome ofTreasurer
ALEXANDRIA CORONADO 1155-15TH STREET, NW
Mailing Address
SUITE 410 .
.WASHINGTON
Title or Position V
CITY A
CHAIRMAN / TREASURER
Full Name of Designated Agent
DC
20005 ZIP CODE A
STATE A
703
Telephone number
_
868
_
1776
SCOTT B MACKENZIE 11SS - 1STH STREET, NW
Mailing Address
SUITE 410 WASHINGTON Title or Position V
CITY A
DEPUTY TREASURER
20005 -
DC
STATE A
Telephone number
703
ZIP CODE A
868
1776
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PAGE
FEC Form 1 (Revised 02/2003)
9.
04/04
Page 4
Banks or Other Oeposilorfas: List all banks or other depositories in which the committee deposits funds, holds accounts, rents safety deposit boxes or maintains funds. Name of Bank. Depository, etc, ,
FIRST VIRGINIA COMMUNITY BANK I
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, 11 325 RANDOM HILLS OR
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Mailing Address
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FE3AN042.POF
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Federal Election Commission ENVELOPE REPLACEMENT PAGE FOR INCOMING DOCUMENTS The FEC added this page to the end of this filing to indicate how it was received. Date of Receipt Hand Delivered Postmarked USPS First Class Mail Postmarked (R/C) USPS Registered/Certified Postmarked USPS Priority Mail Delivery Confirmatkjn ™ Label Postmarked USPS Express Mail
Postmark Illegible
No Postmark Shipping Date Overnight Delivery Service (Specify): Date of Receipt Received from House Records & Registration Office Date of Receipt Received from Senate Public Records Office Date of Receipt Received from Electronic Filing Office Date of Receipt or Postmarked NX
Other (Specify):
The document preceding this page was received by FAX at the FEC. The receiving FAX machine has printed at the bottom of each page the date and time of receipt, the phone number of the transmitting machine and the sequential page numbers.
N/A PREPARER (5/2004)
N/A DATE PREPARED