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Form CPF M 102-0: Campaign Finance Report <br />Municipal Form <br />Comm Office of Campaign and Political Finance <br />Please rant or ey iq�w <br />cept signatures. <br />City or Town of: <br />(eporting Period: Beginning: <br />Ending: <br />(MV1/DD/YYYY) <br />Fype of Report: (Check One) <br />8th day preceding preliminary/primary E] 8th day preceding election ❑ 30th day following election (town or special) �20tb day of January (Year -End report) <br />1. 1 certify that I am a candidate for or currently hold Municipal Office. <br />2. 1 certify that I have not received any contributions, made any expenditures, or incurred any obligations during this reporting period, and do not have a campaign fund in existence. <br />3. 1 certify that I do not have a political committee. <br />SIGNATURE RESIDENTIAL ADDRESS <br />DATE PRINT NAME Signed under the penalties of perjury (Street and Number) OFFICE SOUGHT <br />