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Form CPF M 102: Campaign Finance Report <br /> Municipal Form <br /> Office of Campaign and Political Finance <br /> Commonwealth P, E I D <br /> of Massachusetts <br /> File with: Cit or Town Clerk or Election Commission <br /> Fill in Reporting Period � w Wiffil ig Rate: 2 g °Z Eliding Date: <br /> � 2- <br /> 1 OWN <br /> CLERK <br /> Type of Report: (Check ons <br /> ❑ 8th day preceding preliminary ❑ 8th day preceding election [❑ 30(lay after election ❑ year-end report ❑ dissolution <br /> Candidate Full Name(if applicable) Committee Name <br /> Office Sought and District Name of Committee Treasurer <br /> Residential Address Comling Address <br /> E-mail• E-mail: �t;,, �c y,' <br /> Phone#(optional); Phone#(optional): <br /> SUMMARY BALANCE INFORMATION: <br /> Line 1: Ending Balance from previous report ,�;-s-I <br /> Line 2: Total receipts this period(page 3, line 11) <br /> Line 3: Subtotal(line l plus line 2) L—A <br /> � r + <br /> Line 4: Total expenditures this period(page 5, line 14) os s e, e <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 /> Affidavit 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 /> activity,including all contributions,loans,receipts,expenditures,disbursements,in-kind contributions and liabilities for this reporting period and represents the campaign <br /> finance activity of all persons acting under the aut or on be/hhaa of its committee in accordance with the requirements of M.G.L.c,55. <br /> Signed under the penalties of perjury: G (Treasurer's signature) Date: lel?—7-- <br /> FOR <br /> FOR CANDIDATE FILINGS ONLY: Affidavit ol'Candidate:(check I box only) <br /> Candidate with 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. 1 have not received any contributions, <br /> incurred any liabilities nor made any expenditures on my behalf during this reporting period that are not otherwise disclosed in this report. <br /> Candidate without Committee <br /> f7I certify that 1 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 candidate in accordance with the requirements of M.G.L.c.55. <br /> Signed under the penalties of perjury: Date: <br /> (Candidate's signature) <br />