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FEC FORM 2

STATEMENT OF CANDIDACY

FILING FEC-732679

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1. Nan Hayworth

    NOTE: Address is different than previously reported

P. O. Box 188
Carmel, NY 10512

2. Identification Number: H0NY19139

3. Party: Republican Party

4. Office Sought: House of Representatives

5-6. State & District of Candidate: New York - 19

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DESIGNATION OF PRINCIPAL CAMPAIGN COMMITTEE

7. I hereby designate the following named political committee as my Principal Campaign Committee for the 2012 election(s).

    Friends of Nan Hayworth
    FEC ID #: C00466490

    P. O. Box 188
    Carmel, NY 10512

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DESIGNATION OF OTHER AUTHORIZED COMMITTEES

8. I hereby designate the following named committee, which is NOT my principal campaign committee, to receive and expend funds on behalf of my candidacy.

    Team 2012
    FEC ID #: C00493817

    228 S. Washington St., Ste. 115
    Akexandria, VA 22314

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DECLARATION OF INTENT TO EXPEND PERSONAL FUNDS (House or Senate Only)

9. I intend to expend personal funds exceeding the threshold amount (see 11 C.F.R. 400.9) by

    9A. 0.00 for the primary election, and
    9B. 0.00 for the general election

Signed as: Nan Hayworth
Signed by the candidate on: 06/28/2011

Filed: 06/28/2011

(End FEC FORM 2)

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