SUCCESSFUL CANDIDATES

TO BE RETURNED BY THE ELECTION OFFICIAL WITHIN FIVE (5) DAYS AFTER THE ELECTION

RETURN TO:    STATE ETHICS COMMISSION
                            5000 THURMOND MALL, SUITE 250
                            COLUMBIA, SC  29201

FROM:                _____________________________     ___________________________________
                            (NAME OF AGENCY)                            (ELECTION OFFICIAL)

                            _____________________________     ___________________________________
                            (AGENCY CONDUCTING THE             (TITLE)
                            ELECTION, IF DIFFERENT
                            FROM ABOVE)

                            _____________________________     ___________________________________
                            (STREET ADDRESS)                                (TELEPHONE NUMBER)

                            _____________________________     ___________________________________
                            (CITY, STATE, ZIP)

THE FOLLOWING WERE SUCCESSFUL IN AN ELECTION HELD ON: ___________