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Form CPF M101: STATEMENT OF ORGANIZATION CANDIDATE'S COMMITTEE MUNICIPAL FORM _ f co„mr„onwealth Office of Campaign and Political Finance of Massachuscits 2018 NOY 3 3 AN 9., 20 Filc+villi: City/Town Clerk or Election Commission NOTICE IS HEREBY GIVEN in accordance with therovisions of General Laws,Chapter 55,as amended,of the or t ra t �� t P P la�m�$��' � M A candidate's committee as follows: CANDIDATE: Full Name: C, Residential Address: 2 Gi City I State/Zip: �tt k r , � E-Mail Address, CQ Lt e.11 �� h r-vC 3 t 5`'`S : C' , e�t Phone#: -i . 0 2 Party Affiliation: (If applicable) OFFICE SOUGHT/PURPOSE: Title: G- District: COMMITTEE: Name of Committee: 41--t t TT~ee I, C� { vl (The name of the committee must include the candidate's last name) Committee Mailing Address: � �_ City I Stele l Zip: k i z +-• 07 LI Q.{ Phone OFFICERS: Chairman: 1�4 t a� (' , _�, Treasurer*: TL_ Residential Address:2 Gr Residential Address: "2 City/Slate/Zip: L� iX i P� t-� f`4 /0 V-l 2( City/State/Zip: r ^` -y Phone#: 77( (1`JA Z Phone#C 7g -ry . �gy'�Enmail: ” f— oto�'! !�G.'I C � *A ublic employee inay not serve as treasurer of any political cominittea see reverse). Other Officer/Tide: Other Officer/Title: Residential Address: Residential Address: City I State I Zip: City!State 1 Zip: Phone#: Phone#: (Complete and attach a Form CPF M A 101,if necessary,with other officers and finance committee,i f any.) I hereby consent to the filing 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: r.._. Date: ( d 3 Candida 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.c,55,including the timely filing of campaign finance reports and keeping detailed accounts and records of all campaign finance activity for a period of six years from the date of the relevant election;2)if after my acceptance of this office I become an appointed public employee,I must resign this position and notify OCPF of my resignation;and 3)a candidate may not serve as treasurer of the political committee organized on his/her behalf. SIGNED UNDER THE PENALTIES OF PERJURY: MM Date: 1 a Treasurer' ignature T hereby accept the office of Chairman of the above-named committee. SIGNED UNDER THE PENALTIES OF PERJURY: . ( + Date: jj Chairman's ignature t o !