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City or Town of 44 cj Candidate Name v <br />Please print or type all information, except signatures. <br />Pill in dates: <br />Month <br />Day Year <br />Month Day <br />Year <br />Reporting Period Beginning <br />_ <br />t 0 <br />Ending -c-k at <br />10 <br />Type of Report: (Check One) <br />8th day preceding 8th day preceding election 30th day following election r-1 24th day of January <br />preliminary /primary (Town or Special) (Year -End Report) <br />Pursuant to M.G.L., Chapter SS: <br />1. I certify that I am a candidate for or hold Municipal 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. I certify that I do not have a political committee. <br />W <br />