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Form CPF M101 BQ: STATEMENT OF ORGANIZATION BALLOT QUESTION COMMITTEE r MUNICIPAL FORM Commonwealth Office of Campaign and Political Finance w=: of Massachusetts File with: City/Town Clerk or Election Commission til MI.A,1' 17 AM 10w' 0 11 NOTICE IS THEREBY GIVEN in accordance with the provisions of General Laws,Chapter 55,of the organi atioli fF-4�ft 4"ion committeea f llo rs- EXIN� = 1. Name(See note 1 : ; = a • 1 Vn,r; �}_'.', *'s.`'i'. ark'-}iF^`��s`Fs1's-z::2.• :lam . Committee mailing address: i1c er C i City/State/Zip: le I 14 E-mail Address: L�AS �q!> L— (i2, 0-VI -0 a-n Phone :'VSAS- 'So 5Z . Purpose/specific issues 3+%� C(cA � _26 Z- � �4 LPA and interest See note • ' bvL'kck'v� rp t<::T . Topic of question S { question no.,if known: S . This committee is formed to(check orae): PQsupport or oppose the question. . OFFICERS: . Chairman: � r Treasurer". Residential Address: '` t Residential Address: City/State I Zip= Lsk>c�I '• tc>n 0; City 1 State I Zip: Lj2k.. Z- Phone#: �a� Phone#: *A public employee may not serve as treasurer of any political committee(see reverse). OtherOfficer/Title- Other Officer/Title: Y Residential Address: Residential Address: City/State 1 Zip: City/State/Zip: Phone#: Phone4: omplete ars attae a Form CPF M A 101,if necessary,with other officers and finance committee,if any.) The chairman and treasurer of a political committee should be aware that provisions of M. .L.c. 55 specify that each treasurer of a political committee skull keep and preserve detailed accounts,vouchers and receipts for a period of six gears from the date of the relevant election. Chapter 55 also specifies that no expenditures shall be made for,or on behalf of,a political committee without the authorization ofthe chairman or treasurer, or their designated agents; and,that all funds of a political committee shall be kept separate from any personal funds of any officers,members or associates of such committee. I hereby accept the office of Chairman of the above-named committee. SIGNED UNDER THE PENALTIES OF PERJURY: At Date: Chairman's signature I hereby accept the office of Tre as ur r ofthe above-named coin mitt e.I affirm that I am not a.public employee as d efi ned by M.G.L.e.5 5,s. 13.I understand that: I I am subject to certain duties and Iiabilities under M.G.L.c.5 5, including the t!mely filing of campaign finance reports and beeping detailed accounts and records of all campaign finance activity for a period of six years from the date of the relevant election;and if after my acceptance of this office I become an appointed public employee,I must resign this po i.tion and notify OCPF of my resignation. SIGNED UNDER THE PENALTIES OF PERJURY: f Date: '-- Treasurees sig ature