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f Form CP M101: STATEMENT OF ORGANIZATION CANDIDATE'S COMMITTEE MUNICIPALsFORT Commonwealth Office of Campaign and Political Finance of Massachusetts Filewith- City/Town Clerk or Election Commission NOTICE IS HEREBY GIVEN in accordance with the provisions of General Laws,Chapter 55, as amended, of thee, r ani i n of a candidate's committee a follows: 4 1-,... x ✓ CANDIDATE: Full Name: � Je e,ki � ' �...- Residential Address- Ree City 1State dip. Le)c k . . E-Mail Address. � 1 � � � ��. t � � ",1PhoneNJ c Party Affiliation: w If applicable) OFFICE SOUGHT/PURPOSE: Title: 0 _ District: NMTT , Naive ofCommittee: � � `� � � (The name of the eommitt must include the candidate's last naive) Committee Mailing Address: City State!Zip: LQ ` ; `'�1 VAo-1-42-1 Phone#: OFFICERS: Chairman: 'Treasurer*: U Residential Address: Residential Address: { C4 City/State/Zip: city/State f Zip: r �- w Phone#; Phone##: Y60l� �� inail: � . �� 446� UM - *A i2ubIic em r I ov e ina not serve as treasurer of gMp oIitical committee see reverss. Other Officer/T'it]e: Other Offt cer/Tit]e: Residential Address: Residential Address: City/State I Zip: City 1 State I Zip: Phone : Phone : omplete and attach a Donn 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 aro required to keep detailed accounts and records of all campaign finance activity for a period of six years from the elate of the relevant election. - SIND UNDER THE PENALTIES OF PERJURY: Date: l' . Candidate'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.01,1,c.55,s. 13.I understand that: 1 I am subject to certain duties and liabilities under M. .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 fi•orn the date of the relevant election; if atter my acceptance of this office I become ars appointed public employee,I must resign this position and notify OCP 'of my resignation;and a candidate may not serve as treasurer of the political committee organized on his/her behalf. SIGNED SER THE PENALTIES OF PERJURY: ,}� Date: Y ,r Treasurer's signature I hereby accept the office of Chairman of the above--named committee. SIGNED UNDER THE PENALTIES OF PERJURY: Date: Chairman's signature