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ClaEanel <br />of Muupnno <br />Form CPF M 102.0; Campaign Finance Report <br />Municipal Form <br />Orate of Campaign and Political Finance <br />City or Town of <br />Candidate <br />Please print or type all information, except signatures, <br />Office <br />IIII In dates( Month Day Year Month Day Year <br />Reporting Period Beginning Ending <br />Type of Report: (Check One) . <br />o 8th day preceding 0 8th day preceding election 0 30th day following election 0 20th day of January <br />preliminary/primary (Town or Special) (Year•End Report)' <br />Pursuant to M,G,L., Chapter 55: <br />I. I certify that 1 am a candidate for or hold Municipal Office, <br />2. I certify that 1 have not received any contributions, made any expenditures, or Incurred any obligations during this <br />reporting period, and do not have a campaign find In existence, <br />3, I certify that 1 do not have a political committee. <br />DATE . <br />1. SIGNATURE <br />Signed under the penalties of perjury <br />II: RESIDENTIAL ADDRBSS <br />(Street and Number) <br />' 111, OFFICE SOUGHT <br />,.., <br />r_ <br />cc <br />0 <br />