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Form CPF M109: <br /> Statement of Municipal Candidate <br /> Not Raising or Expending Campaign Funds <br /> Commonwealth <br /> of Massachusetts Office of Campaign and Political Finance <br /> File with: Local Election Official(City or Town Clerk) <br /> Candidate's Name: <br /> Office Sought: <br /> Residential Address: f <br /> 2 <br /> City 1 State/Zip: 1T oa o, <br /> co <br /> � 1 T7 p <br /> E-Mail Address: 10��C��e�� �GzU �.. �C�r�.._ Phone Number: <br /> i <br /> I hereby certify that I have not opened a campaign bank account for campaign funds because I do not intend to accept <br /> contributions or in-kind contributions,make expenditures,including expenditures of my own funds, or incur liabilities <br /> for any campaign-related purpose, nor do I currently have any outstanding liabilities for prior campaign-related activity. <br /> I submit the following as my campaign report for all bank reporting periods in this calendar year as provided for in Chapter 55 <br /> of the Massachusetts General Laws: <br /> 1. Ending balance from previous report ZERO <br /> 2. Total receipts for reporting period ZERO <br /> 3. Subtotal ZERO <br /> 4. Total Expenditures for reporting period ZERO <br /> 5. Ending balance ZERO <br /> After filing this statement,if I decide to raise, accept,or expend funds, or incur liabilities,for a campaign-related <br /> purpose,I will immediately notify my local election official in writing, and will file periodic campaign finance reports <br /> according to the statutory filing schedule. <br /> Until such notice is on file with the local election official, I certify that the above Zero report will be in effect for each <br /> reporting period,in the calendar year in which it is filed,required by Chapter 55 of the Massachusetts General Laws. <br /> This form is valid through December 31 of the year in which it was signed. rn «< <br /> �yCY1 CJ r., y�3 <br /> SIGNED UNDER THE PENALTIES OF PERJURY: : <br /> CO <br /> Candidate's signature: Date: 4 t F-E� ��3 <br /> MI01 12/21 <br />