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Form CPF M 102: Campaign Finance Report <br /> lug Municipal Form <br /> Office of Campaign and Political Finance <br /> Commonwealth <br /> of Massachusetts <br /> File with: City or-town Clerk or Election Commission <br /> Fill in Reporting Period dates: Beginning Date: y j Ending Date: <br /> Type of Report: (Check one) <br /> ❑ 8th day preceding preliminary ❑ Rth day preceding election ❑ 30 day after election ❑ year-end report ❑X dissolution <br /> Candidate Full Name(if applicable) Committee Name <br /> Office Suught and District �7 ! Name of Committee Treasurer y� <br /> Residential Address 1 Committee Mailing/Address <br /> E-mail: E-mail: e l Tt a e s 'C-rr tQCW(_`1e <br /> Phone ft(optional): phone#(optionail: <br /> SUMMARY BALANCE INFORMATION: <br /> Line 1: Ending Balance from previous report d <br /> Line 2: Total receipts this period(page 3, line 11) <br /> P <br /> Line 3: Subtotal(line 1 plus line 2) <br /> Line 4: Total expenditures this period(page 5, line 14) <br /> s <br /> Line 5: Ending Balance(line 3 minus line 4) <br /> Line 6: Total in-kind contributions this period(page G) d '� <br /> Line 7: Total(all)outstanding liabilities(page 7) d <br /> Line S: Name of bank(s) used: <br /> Affidavit of Committee Treasurer: <br /> certify that t have examined this report including attached schedules and it is,to the best of my knu%vledge and bulief,;:true and cumplCte statement of all campaign finantc <br /> activity,including all contributions,loans,receipts,expenditures,disbursements.in-kind cuntributions and liabilities for this reporting period and rcprosenls the campaign <br /> finance activity of all persons acting under the authority o h if of t mmiltee in accordance with the requirements of M.G.L.c.55, <br /> Date: /r1z o1� �Z <br /> Signed under the penalties of perjury: LA G-`� (Treasurer's signature) <br /> FOR CANDIDATE FILING ONLY: Affidavit of Candidate:(check I box only) <br /> Candidate with Committee <br /> ❑ l certify that i have examined this report including attached schedules and it is,to the best of my knowledge and belief,a tate 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 rcquircmcnts of M.CI.L.c.55. 1 have not received any contributions, <br /> incurred any liabilities nor made any expenditures on my behalf during this repotting period that are not othcrnvise disclosed in this report. <br /> Candidate without 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 <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 tinder the authority or on behalf of this candidate in accordance with the requirements of M.G-L.c-55. <br /> Date: <br /> Signed under the penalties of perjury: (Candidate's signature) - -- <br /> 3 <br />