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Form CPF M 102: Campaign Finance Report <br />Municipal Form <br />Office of Campaign and Political Finance <br />Commonwealth <br />of Massachusetts <br />Filewith: City or Town Clerkor Election Commission <br />Fill in Reporting Period dates: Beginning Date: Z h / i `� Ending Date: I I Z ' l <br />Type of Report: (Check one) <br />❑ 8th day preceding preliminary ❑ 8th day preceding election ❑ 30 day after election ❑ year -end report ❑ dissolution <br />Candidate Full Name (if applicable) <br />Office Sought and District <br />Residential Address <br />Telephone Number (optional): <br />SUMMARY <br />Committee Name <br />Name of Committee Treasurer <br />Committee Mailing Address <br />Telephone Number (optional): <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: <br />m1 <br />X <br />ZM <br />CI <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 ofall campaign finance <br />n tivity, including all contributions, loans, receipts, expenditures, disburlemen , m- ind contributions and liabilities for this reporting period and represents the campaign <br />Finance activity of all persons acting under the authority or on behalf of isicd ?nnritto in accordandp with the requirements of M.G.L. a 55. (' <br />Signed under the penalties of perjury: r` -'` �`�. % u _ (Treasurces signature) Date: rR 17 4 <br />FOR CANDIDATE FILINGS ONLY: Affidavit of Candidate: (check I box only) <br />Candidate with Committee and no activity independent of the committee <br />1 certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a trite mrd complete statement of all campaign finance <br />activity, of all persons acting tinder the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55. 1 have not received any contributions, <br />incurred any liabilities nor made any expenditures on my behalf during this reporting period. <br />Candidate without Committee OR Candidate with independent activity filing separate report <br />I certify that 1 have examined this report including attached schedules and it is, to the best of my knowledge and belief, a two 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 authori r behalfofthi committee in accordance with the requirements of M.G.L. c. 55. <br />ed under the penalties ofperJury: (Candidates signature) Date: FT71-STI-111-1 <br />