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Form CPF M 102: Campaign Finance Report <br />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: DA= Date: 1 � `7 -, ` ( <br />Type of Report: (Check one) <br />❑ 8th day preceding preliminary ❑ 8th day preceding election ❑ 30 day after election ear -end report ❑ dissolution <br />Candidate Full Name (if applicable) <br />Office Sought and District <br />Residential Address <br />Telephone Number (optional): (�i 0o 4--7 - <br />SUMMARY BALANCE <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 />Committee Name <br />Name of Committee Treasurer <br />Committee Mailing Address <br />'telephone Number (optional): <br />Line 4: Total expenditures this period (page 5, line 14) <br />Line 5: Ending Balance (line 3 minus line 4) <br />RMATION: <br />I v <br />N <br />E <br />ka <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 />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�jaijjthori or on behalf of this committee in accordance with the requirements of M.G.L. c. 55. <br />Signed under the penalties of perjury: 4 ``" �� (Treasurer's signature) Date: {, OL. <br />Affidavit of Candidate: (check 1 box only) <br />Candidate with Committee and no activity independent of the committee <br />1 certify that I have examined this report including attached schedules and it is, to lite best of my knowledge and belief, a true mid complete statement of all campaign finance <br />© activity, of all persons acting under the authority m 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 Puling separate report <br />E]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 />cmnpaign finance activity of all persons acting under (lie 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: �- '�� (Candidate's signature) Date: <br />r <br />