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Form CPF M 102-0: Campaign Finance Report <br />Municipal Form <br />orrice or campaign and Political Finance <br />c o mmonwealth <br />ormanachusetty (j,— — I) <br />City or Town of. <br />CD <br />Please print or type all information, except signatures, <br />'ill in dates: Month Day Year Month Day Year <br />keporting Period Beginning Ending 2A)LI <br />hype of Report: (Check One) <br />13 8th day preceding 8th day preceding election 30th day following election 20th day of January <br />preliminary/primary (Town or Special) (Year-End Report)' <br />Pursuant to M.G.L., Chapter 55: <br />1. 1 certify that I am a candidate for or hold Mu * nicipal Office, <br />2. 1 certify that I have not received any contributions, made any expenditures, or incurred any obligations during this <br />reporting period, and do not have a campaign fund in existence. <br />3. 1 certify that I do not have a political committee. <br />DATE <br />1, SIGNATURE <br />Signed under the penalties of perjury <br />11. RESIDENTIAL ADDRESS <br />(Street and Number) <br />111. OFFICE SOUGHT <br />11171 <br />r- <br />