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STATEMENT OF
FEC
FORM1 ORGANIZATION
(See instructions) on*««i,

1.
fc

NAME OF ~ (Check if name Example: If typying. type P 4JTT"<r™T r

^"""l
COMMITTEE (In 1ull) | J is changed) over the lines | 12rE4ryl5, «

| i ^WWY^WW. i . . i i i . . . i i . i . i i i 1
|_L 1 I 1 i 1 I i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i t i i1
l 1 1 55 -15TH STREET i
ADDRESStaunbvand i•"•"i | i |_ l i i i i i i i i i i i i i i i i i i t i i i i i i i i | i i I

1 r i Til l i i i i l i l l l i i i i i i i i i i i i i i i i i i1
D (CneckHaddn
is changed)
1 yv^sHifjoyop ( , , , , , , , , , , | L 9CI 1 i I29OCI5I-I i i i 1
CITY A STATE A. ZIP CODE A.
COMMITTEE'S E-MAIL ADDRESS
i scott@FECrep
"^•P0!", . . i i , . i i , , , , . , , , , , , I
| , 1 I 1 1 1 I , , , , , , , , , f , , , , , , , I

COMMITTEE'S WEB PAGE ADDRESS (URL)

I i l i i i i i l l i i i i I I i i l l I i i L

I i i
COMMITTEE'S FAX NUMBER
3202159696
l I i

ii

2. DATE " «]' V Y Y v

3. FEC IDENTIFICATION NUMBER

4. IS THIS STATEMENT JXJ NEW(N) OR fj 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

SC
Type or Print Name of Treasurer °7!JP>*^ENZIE

Signature of Treasurer El NZIE Date 'j, rI

'i'
C
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

[Office For further information contact: ecr> CrtDM <t

Use Federal Election Commission rtV/ rUKIVI 1
(Only Toll Free 800-424-3530 (Revised 02/2003)
Local 202-694-1100
FE3AN042.PDF

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FEO-ornM (Revised 02/2003) Page 2

6. TYPE OF COMMITTEE (Check One)

(a) j^jj This committee is a principal campaign committee. (Complete the candidate information below.)

(b)
n
jj^J This committee Is an authorized committee, and is NOT a principal campaign committee. (Complete the candidate
information below.)

Name of
Candidate I i i I I I i I I I i i i i i i i i i i i i i i i i i i i i i i i j i i i \_

Candidate state
Party Affiliation LJ™ .j ' Souflht:
lJ House
LJ Senale
Li President

i \ This committee supports/opposes only one candidate, and is NOT an authorized committee.

Name of
Candidate _; L.J-._J L. I I i I I IIjJ

r-jj T.~T.-~; (National. State p"-"1 (Democratic,

tJ
*W*
This commlitee is a [ . i [
•w.-wihMif.Ainli.^.
(or subordinate) committee of the »HrtiItef.h
I --
Republican,etc.) Party.

(e) D This committee Is a separate segregated fund

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

I None.I I II I I I I I ! I I I I I I I I I I I I I I I I I I I I I I I I I I I I | I.

I I I I

Mailing Address

I I i i i_ |____|_j_ L_l_ L_L_! _ i i i I I II _ !_J_J _ LJ_ I

I J- I I I I I I I I I I I I I" I I I I J I I I I I l-l I I I |

CITY A STATE* ZIP CODE A

Relationship

Type of Connected Organization:

LJ Corporation LJ Corporation w/o Capital Stock ^J Labor Organization

| I Membership Organization F i Trade Association I j Cooperative

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FECFomH (Revised 02/2003) Page3

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
Full Name i i _i_ i i I i i i i

Mailing Address 1155 -1STH STREET, NW

SUITE 410

WASHINGTON DC 20005 -

Title or Position V CITY A STATEA ZIP CODE A

DEPUTY TREASURER 703 868 1778

Telephone number

e. 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

Mailing Address 1155-15TH STREET, NW

SUITE 410

. .WASHINGTON DC 20005 -

Title or Position V CITY A STATE A ZIP CODE A

CHAIRMAN / TREASURER 703 _ 868 _ 1776

Telephone number

Full Name of
Designated
Agent SCOTT B MACKENZIE

Mailing Address 11SS - 1STH STREET, NW

SUITE 410

WASHINGTON DC 20005 -

Title or Position V CITY A STATE A ZIP CODE A

DEPUTY TREASURER
Telephone number
703 868 1776

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FEC Form 1 (Revised 02/2003) Page 4

9. 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 .

III I I I '• j I | I I I I I I I I I I I I I I I I I I I I I I I I _|_ | I I | |

, AJJ , 11 325 RANDOM HILLS OR ,

Mailing Address I i i i i i i i i j _ i i i i i i i .j_ i_j_ L i i i i i i_ i i i i__i__i i_ |

I T r T i i i i i i i i ^ i i

U
CITY A STATE A ZIP CODE A

Name of Bank, Depository, etc.

I l_l I I I 1 I 1 I I I I I I I I _l_ I I I I I I I I J_l I I I II I ! I LI I

Mailing Address |

I i i i i i i i i i i i i i i i i i I I i I I i i i i j —

CITY 4 STATED ZIP CODE A

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
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Postmark Illegible

No Postmark

Shipping Date
Overnight Delivery Service (Specify):

Date of Receipt
Received from House Records & Registration Office

Date of Receipt
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Date of Receipt
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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 N/A
PREPARER DATE PREPARED
(5/2004)