File with: City or Town Clerk or Election Commission
<br />Fill in Reporting Period dates: Beginning Date: 1 :' ( t ' ^ ¢ Ending Date: !'
<br />Type of Report: (Check one)
<br />❑ 8th day preceding preliminary ❑ 8th day preceding election ❑ 30 day after election year -end report ❑ dissolution
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<br />Candidate Full Name (if applicable)
<br />Office Sought and District
<br />`r)g' =i t,E f t-, y f ,
<br />Residential Address
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<br />Telephone Number (optional):
<br />Committee Name
<br />Name of Committee Treasurer
<br />Committee Mailing Address
<br />Telephone Number (optional):
<br />SUMMARY BALANCE INFORMATION:
<br />Line 1: Ending Balance from previous report
<br />Line 2: Total receipts this period (page 3, line 11)
<br />Line 3: Subtotal (line 1 plus line 2)
<br />Line 4: Total expenditures this period (page 5, line 14)
<br />Line 5: Ending Balance (line 3 minus line 4)
<br />Line 6: Total in -kind contributions this period (page 6)
<br />Line 7: Total (all) outstanding liabilities (page 7)
<br />Line 8: Name of bank(s) used: '1
<br />,ffidavit of Committee Treasurer:
<br />certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance
<br />tivity, including all contributions, loans, receipts, expendittues, disbursements, in -kind contributions and liabilities for this reporting period and represents the campaign
<br />nance activity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55.
<br />under the penalties of perjury:
<br />Affidavit of Candidate: (check i box only)
<br />(Treasurer's signature) Date: I_..�
<br />Candidate with Committee and no activity independent of the committee
<br />I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance
<br />❑ activity, of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55. I have not received any contributions, !I
<br />incurred any liabilities nor made any expenditures on my behalf during this reporting period.
<br />I
<br />Candidate without Committee OR Candidate with independent activity filing separate report
<br />I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign
<br />finance activity, including contributions, loans, receipts, expenditures, disbursements, in -kind contributions and liabilities for this reporting period and represents the
<br />campaign finance activity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55.
<br />Signed under the penalties of perjury: / E r i✓ -- (Candidate's signature) Date: r
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<br />,ffidavit of Committee Treasurer:
<br />certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance
<br />tivity, including all contributions, loans, receipts, expendittues, disbursements, in -kind contributions and liabilities for this reporting period and represents the campaign
<br />nance activity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55.
<br />under the penalties of perjury:
<br />Affidavit of Candidate: (check i box only)
<br />(Treasurer's signature) Date: I_..�
<br />Candidate with Committee and no activity independent of the committee
<br />I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance
<br />❑ activity, of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55. I have not received any contributions, !I
<br />incurred any liabilities nor made any expenditures on my behalf during this reporting period.
<br />I
<br />Candidate without Committee OR Candidate with independent activity filing separate report
<br />I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign
<br />finance activity, including contributions, loans, receipts, expenditures, disbursements, in -kind contributions and liabilities for this reporting period and represents the
<br />campaign finance activity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55.
<br />Signed under the penalties of perjury: / E r i✓ -- (Candidate's signature) Date: r
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