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Form CPF M101: STATEMENT OF ORGANIZATION CANDIDATE'S COMMITTEE MUNICIPAL FORM Commonwealth Office of Campaign and Political Finance of Massachusetts Zola gQV 26 Ed, ' File with: City 1 Town Clerk or Election Canmission NOTICE IS HEREBY GIVEN in accordance with the provisions of General Laws,Chapter 55,as amended,of then i a oti a candidate's committee as follows: CANDIDATE: Full Name: Residential Address: r�-t c iA y City I State I Zip: � � Y r �� E-Mail Address: . ; rr-A'i. C, �a� ` CttL V, Phone#; € fv � � Party Affiliation: (If applicable) OFFICE SOUGHT/PURPOSE: Title: C% r,L L,)` i District: ? t otlG COMMITTEE: Name of Committee: (The name of the committee must include the candidate's last name) f Committee Mailing Address: Phone#: City l State I Zip: Z_X IAIC_�- S 7 F i OFFICERS: Chairman: ti y� r� . TreasuA 0 Residential Address: Residential _ City 1 State I Zip: L G fAk 0,'L4.,Lo City/State l Zip: �/ r �' Phone#:(Dn-(.V'\. �� . Phone#: �1 `� �� t. ��.fGX' Ll i *A public employee may not serve as treasurer of any political committee see reverse)-. i Other Officer/Title: Luh ��H _ K r Other OfficerlTitte: Residential Address:_ 180 �- Residential Address: r City/State 1 Zip: � Jil ZA�> City!State 1 Zip: Phone#: $f •(�3'L 2Z�;q� Phone#: (Complete and attach a Forin CPF M A 101,if necessary,with other officers and finance committee,if any.) I hereby consent to the tiling of this committee. I understand that a candidate shall not give consent to the organization of more than one committee on his/her behalf. I am aware that candidates are required to keep detailed accounts and records of all campaign finance activity for a period of six years from the date of the relevant election. SIGNED UNDER THE PENALTIES OF PERJURY: "" - `'..-�/, Date: i llz-(_- f Candidate's signature I hereby accept the office of Treasurer of the above-named committee.I affirm that I am not a public employee as defined by M.G.L.c.55,s. 13.I understand that: 1)I am subject to certain duties and liabilities under M.G.L, 55—, melutdi1.�the timely filing of campaign finance reports and keeping detailed accounts and records of all campaign finance activity for a period of si• ears from the dat`e�f the relevant election;2}if after my acceptance of this office I become an appointed public employee,I must resign this position and n tify OCPF of to resigna n;and 3)a candidate may not serve as treasurer of the political committee organized on his/her behalf. SIGNED UNDER THE PENALTIES OF PERJURY; Date: TCca ! F's atut I hereby accept the office of Chairman of the above-named committee, SIGNED UNDER THE PENALTIES OF PERJURY: Chairman's sign r Data:�. ��