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Commonwealth <br />of Massachusetts <br />Form CPF M 102: Campaign Finance Report <br />Municipal Form <br />Office of Campaign and Political Finance <br />Fill in Reporting Period dates: <br />File with: City or Town Clerk or Election Commission <br />Type of Report: (Check one) <br />❑ 8th day preceding preliminary ❑ 8th day preceding election ❑ 30 day after election ear -end report ❑ dissolution <br />6651 5 &t12a kt <br />Candidate Full Name (if applicable) <br />c Ga <br />t i U‘;'< WCSTZ>N MR <br />Office Sought and District <br />Ak A Dig 21 <br />Telephone Number (optional): <br />Residential Address <br />J SITA6c- 1?uoAZ\--) _{-txt S<_ ltoi 6M 1-1-1 <br />Committee Name <br />l..\ K./ <br />Name of Committee Treasurer <br />2 <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: <br />0 <br />Affidavit of Committee Treasurer: <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, 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 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: <br />(Treasurer's signature) <br />Date: <br />FOR CANDIDATE FILINGS ONLY: Affidavit of Candidate: (check I box only) <br />((; andidate with Committee and no activity independent of the committee <br />Nfi 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 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, <br />incurred any liabilities nor made any expenditures on my behalf during this reporting period. <br />Candidate without Committee OR Candidate with independent activity tiling separate report <br />1 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 ulwer 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: <br />(Candidate's signature) Date: <br />