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6. Liabilities and promises to pay:
<br />Date Made or
<br />Incurred*
<br />To Whom Due
<br />Address
<br />Purpose
<br />Amount**
<br />J r
<br />r>
<br />Total liabilities on this repot
<br />X.
<br />- W r Total liabilities previously reported and currently outstanding
<br />i
<br />Total outstanding liabilities
<br />* A promise to pay exists and must be reported if the corporation, organization or individual has (1) made an express or implied
<br />promise to give, pay, expend or contribute money or anything of value, or (2) knows or reasonably should know that they will
<br />be responsible for paying for a good or service. A liability exists and must be reported if the corporation, organization or
<br />individual has received a good or service which has not been paid for even if the corporation, organization or individual has
<br />not received a bill or invoice.
<br />** if the amount of the liability has not been determined or is in dispute, the liability should be estimated or reported as "to be
<br />determined" or "in dispute."
<br />i certify that this report is a true statement of the amount or value of every gift, payment, expenditure or contribution or promise to
<br />give, pay, expend or contribute in order to influence or affect the vote on the question referenced on the font of this report,
<br />together with the date, purpose, and full name and address of the person to whom it was made. i make this report in accordance
<br />with the requirements of Massachusetts General Laws, Chapter 55, Section 22, as amended.
<br />Signed under he penalties of perjury:
<br />7
<br />Signature of corporation/organization Treasur Ow Individual Print Name Date
<br />M.G.L. Chapter 55, Section 22 states in part:
<br />Any person or the treasurer ofa corporation, association, organization or other group of persons, other than a political committee organized
<br />antler section S, which has given, paid, expended or contributed, or promised m give, pay expend or contribute, any money at, other thing o/
<br />value in at -der to influence or affect the vote on any question submitted to the voters shallfile reports sexing forth the amount or value gl'every
<br />gift, payment, expenditure or contribution or promise to give, pay, expend or contribute, together with Nie date, purpose and fill name and
<br />address of the person to whom it was made.
<br />Any person who makes an expenditure of $250 or more other than a contribution to a ballot question committee or incurs a liability of 5250 at,
<br />more to influence or affect the vote on any question submitted to the voters shall file reports seeing forth the amount or value of the expenditure
<br />or liabili/ty, together with the date, purpose andfur/l name of the person to whom (lie expenditure was made or the liability incurred.
<br />If the question appears on ballots at a city or town election or appears on ballois for use in a city or town at a state election, such report shall
<br />be filed with the city at- town clerk as follows: (1) the eighth day preceding a preliminary or primary, including a caucus, the eighth day
<br />preceding a city or town election and, if a city election, as a final report, the twentieth day ofJamraty in the following year, complete as of the
<br />thirty-first day of December of the prior year and, iit a town election, as a final report, the thirtieth day following such election; (2) the eighth
<br />day preceding a special primary, including a caucus, the eighth day preceding a special election and, as a final report. Nle thirtieth day
<br />following a special election; and (3) tine twentieth day of January ofeach year, complete as of the thirty-frst day of December of the prioryear,
<br />until all declared liabilities ofsuch person or corporation, association, organization or other group ofpersons have been discharged. [Lxcept
<br />for the Jan. 20 report, all reports must be complete as of the preceding tenth day.]
<br />Any person a• corporation, association, organization or other group ofpersons, other than a political committee organized under said section
<br />S, violating any provision of this section shall be punished by a fine ofnot more than $50,000 and any officer, director m• agent of any such
<br />person or corporation, association, organization or other group ofpersons violating any provision hereof or authorizing any such violation or
<br />any person who violates or in any way knowingly aids at- abets the violation of any provision hereofshall be punished by a fine of not more than
<br />510,000 or by imprisonment for not more than one year or by both such fine and imprisonment.
<br />11/09
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