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Form CPF M101: STATEMENT OF ORGANIZATION CANDIDATE'S COMMITTEE MUNICIPAL FORM Commonwealth Office of Campaign and Political Finance of Massachusetts n l• File with: City I Town Clerk or Election Commission NOTICE I5 HEREBY GIVEN in accordance with the provisions of General Laws,Chapter 55,as atnet�d c INJ o, apizat}on of a candidate's committee as follows: ' 3 11, M A CANDIDATE: Full Natne: o !J 4k Residential Address: , y V City/State I Zip: l Axl u. e^r fn {�' 0_&i E-Mail Address: �' GZ�o��e 2,T Z j 6 �� ' C%G7 Phone#: �j l o -�.- '" €^ Party Affiliation: y1,,o C r( (If applicable) OFFICE SOUGHT/PURPOSE: f 1 Title: rt r�f�C t YVI District: "i I'D yy Z, COMMITTEE: Name orCommittee: /� a 1F� So fi e (The name of the committee must include the candidate's last name) Committee Mailing Address: City 1 State/Zip: Phone#: ��) 4 ��--2J O � r OFFICERS: Chairman: �� S d Treasurer*: I-<O Residential Address: S �' � ) j� 7 / Residential Address: lew City I State I Zip: �� l ZG 1 City I State I Zip: Phone#: �� ' `' �� Picone#: *A ublic employee may not serve as treasurer of any political g&nmittee see reverse). Other Officer/Title: Other Officer/Title: Residential Address: Residential Address: City 1 State/Zip: City 1 State 1 Zip: Phone#: Phone#: (Complete and attach a Form CPF M A 101,if necessary,with other officers and finance committee,if 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 11 campaign finance activity for a period of six years from the date of the relevant election. SIGNED UNDER THE PENALTIES OF PERJURY: � Date: Candidate's sf nature I hereby accept the office of Treasurer of the above-named comtmitte 4 ffirm that I am not a public employee as defined by M.G.L,c.SS,s. 13.I understand that: 1}I am subject to certain duties and liabilities under M.G.L. . ,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: f Bate: Treasurer's sign e �� I hereby accept the office of Chairman of the above-named committee. SIGNED UNDER THE PENALTIES OF PERJURY: Date: Chai ris signature