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REPORT OF RECEIPTS FEC AND DISBURSEMENTS FORM 3 For An Authorized Committee Office Use Only
1. NAME OF TYPE OR PRINT Example: If typing, type 12FE4M5 COMMITTEE (in full) over the lines. Committee to Re-elect Henry Hank Johnson
4153 Flat Shoals Parkway ADDRESS (number and street) Suite 322, Building C, 2nd Floor
Check if different than previously Decatur GA 30034
reported. (ACC)