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!LIN Form CPF M1.01: STATEMENT OF ORGANIZATION <br /> t' <br /> CANDIDATE'S COMMITTEE <br /> MUNICIPAL FORM <br /> Commonwealth Office of Campaign and Political Finance <br /> of Massachusetts <br /> C <br /> File with: City I Town Clerk or Election Commission <br /> NOTICE IS HEREBY GIVEN in accordance with the provisions of General Laws,Chapter 55,as amended,of the W�iizat t of�k <br /> candidate's committee as follows: t I E <br /> CANDIDATE: Full Name: 9 �r <br /> Residential Address: <br /> City/State I Zip: L ca__ r 1 t O <br /> E-Mail Address: , b(_0 Phone#: 7I <br /> Party Affiliation: (If applicable) <br /> OFFICE SOUGHT/PURPOSE- <br /> Title: <br /> District: <br /> COMMITTEE: Name of Committee: ! 6 / . <br /> 1,.. _ ` 1 t <br /> (The name of the committee must include the candidate's last name) <br /> Committee Mailing Address: �,( J1 <br /> City I State 1 Zip: �J, ,�d Phone#: <br /> OFFICERS: ( f <br /> Chairman: Treasurer*: Ham 6t <br /> Residential Address: <br /> J Residential Address: 1W, <br /> Cityl State I Zip: t � ial 11—pt �c City I State I Zip: ��t Y �7j} /� ' 44-4 4414 02—q I#: 7,1-f �5_6 UL Phone#: j IO-Cy_7 mail: [ tji rGbtQ i r� GA C(/YL. <br /> *A vublic employee may not serve as treasurer of any polii1cal committee see reverse <br /> Other Officer/Tide: Other Officer/Title: <br /> Residential Address: Residential Address: <br /> City I State I Zip: City I State I Zip: <br /> Phone#: Phone#: <br /> (Complete and attach a Form CPF M A 101,if necessary,with other officers and finance committee,if any.) <br /> 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 <br /> 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 <br /> the relevant election. <br /> SIGNED UNDER THE PENALTIES OF PERJURY: j <br /> -; Date: <br /> L 1 ( <br /> Candidate's signature 1 <br /> 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 <br /> 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 <br /> 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 <br /> 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 <br /> committee organized on his/her behalf, <br /> SIGNED UNDER THE PENALTIES OF PERJURY: (�GG U _ Date: 117,11 <br /> Treasurer's signatu e <br /> I hereby accept the office of Chairman of the above-named committee. <br /> SIGNED UNDER THE PENALTIES OF PERJURY: <br /> Chairman's signature� Date' f I <br />