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A4, G.L. c. 55 requires that the name and residential address be reported, in alphabetical order, for all receipts <br />oiler $50, in a calendar year. Committees must keep detailed accounts and records of all receipts, but need only <br />it4qrtize those receipts over $50. In addition, the uccupatiors and employer must be reported for all persons who <br />e(yarlbute $200 or more in a calendar year. <br />1'1 page may be copied if additional pages are required to report all receipts. Please include your committee name and a page <br />.,t,,.r nn each naEe. <br />Date <br />lteceived <br />°- <br />Name and Residential Address <br />(alphabetical listing required) <br />Amount <br />Occupation & Employer <br />(for contributions of $200 or more) <br />Pa <br />(.n <br />, <br />Line 9: Total receipts in excess of $50 (or listed above) <br />f 0 0 <br />a e <br />Enter on page 1, line 2 <br />—1- Ehnen rPaintc not itP.Mi7 <br />..t..,.AA : 1-4. r <br />Line 10: Total receipts $50 and under* (not listed above) <br />Line 11: TOTAL RECEIPTS IN THE PERIOD <br />.1_� e_ u__ <br />n r <br />1n <br />* If you have itemized receipts or $50 and unaer tnctuue utcut to ,tltc 7. Alit". iv Jl1VULU a—A— —1- ....,.n, ....,... <br />above. Page 2 <br />ed <br />