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Form CPF M 102 -0: Campaign Finance Report <br />Municipal Form <br />Office of Campaign and Political Finance <br />Coao�wonwaph , <br />of Mauachuunt <br />City or Town of: LZ5X1A17 /O/L-/� <br />Please print or type all information, except signatures. <br />Fill in dates: <br />Month <br />Day <br />Year <br />Month <br />Day <br />Year <br />Reporting Period Beginning <br />/ / <br />1 <br />20/0 <br />Ending )— <br />! r <br />Z / <br />Type of Report: (Check One) <br />r-1 8th day preceding 1 j° 8th day preceding election 13 30th day following election 20th day of January <br />preliminary/primary (Town or Special) (Y ear -End Report)' <br />Pursuant to M.G.L., Chapter 55: <br />1. I certify that I am a candidate for or hold Municipal Office, <br />2. I 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 />DATE <br />I. SIGNATURE <br />Signed and -the enalties of perjury <br />II. RESIDENTIAL ADDRESS <br />(Street and Number) <br />III, OFFICE SOUGHT <br />4,1� 15©s�,,) <br />N <br />rn -f <br />V ' <br />$f <br />M N � <br />W <br />ij <br />