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Form CPF" M 102; Campaign Finance Deport <br /> Municipal Form <br /> Office of Campaign and Political Finance <br /> Comroomvealth i <br /> JAI! 22 P11 7: 04 <br /> of Massachusetts <br /> File with: City or Town Clerk or Election Commission <br /> Fill in Reporting Period da ► j 13 triiig Date: a Ending Date: <br /> p g � fN l • n <br /> Type of Report: (Check one) <br /> ❑ 81h day preceding preliminary 8th day preceding election 30 day after election ear-end report dissolution <br /> r, <br /> Candidate Full Name(if applicable) Committee Name <br /> Office Sought and District Name of Committee Treasurer <br /> 1 <br /> Residential Address Committee Mailing Address <br /> Telephone Number(optional): " � � Telephone Number(o donaf) <br /> : <br /> SUMMARY BALANCE INFORMATION: <br /> Line 1: Ending Balance from previous reports <br /> Line 2: Total receipts this period(page 3,line 11) <br /> Line 3: Subtotal(line 1 plus line 2) e <br /> Line 4: Total expenditures this period(page 5,line 14) <br /> Line 5: Ending Balance(line 3 minus line 4) � <br /> Line 6: Total in-kind contributions this period(page 6) <br /> Line 7: Total(all)outstanding liabilities(page 7) l <br /> Line 8: Name of bank(s)used: <br /> Affidavit of Committee Treasurer: <br /> I certify that I have examined this report including attached schedules and it is,to the best of my knowledge and belief,a true and complete statement of all campaign finance <br /> activity,including all contributions,loans,receipts,expenditures,disbursements,in-kind contributions and liabilities for this reporting period and represents the campaign <br /> finance activity of all persons acting under th mull rity or on behalf of this committee in accordance with the requirements of M.G.L.c.55. <br /> Signed under the penalties of perjury: (Treasurer's signature) Date: i �.S <br /> FOR CANDIDATE FILINGS ONLY: Affidavit of Candidate:(check 1 box only) <br /> Candidate with Committee and no activity independent of the committee <br /> I certify that i have examined this report including attached schedules and it is,to the best of my knowledge and belief,a true and complete statement of all campaign finance <br /> activity,of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L.c.55. 1 have not received any contributions, <br /> incurred any liabilities nor made any expenditures on my behalf during this reporting period. <br /> Candidate without Committee OR Candidate with independent activity riling separate report <br /> I certify that t have examined this report including attached schedules and it is,to the best of my knowledge and belief,a live and complete statement of all campaign <br /> finance activity,including contributions,loans,receipts,expenditures,disbursements,in-kind contributions and liabilities for this reporting period and represents the <br /> campaign finance activity ofa€l persons acting under the authority or on"alf of this committee in accordance with the requirements of M.G.L.c.55. <br /> Signed under the penalties of perjury: `� r (Candidate's signature) Date: <br />