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Form CPF M 102 -0: Campaign Finance Report ; <br />Municipal Form h,a <br />Office of Campaign and Political Finance 1 2 3 <br />Cerinonwtelth <br />of Mwacbu�etu <br />City or.Town of: A` <br />Please print or type all information, except signatures. <br />Fill in dates: Month Day Year Month Day Year <br />Reporting Period Beginning der l0 �Z®/ Ending <br />Type of Report: (Check One) <br />8th day preceding E 8th day preceding election C 30th day following election 20th day of January <br />preliminary/primary (Town or Special) (Year -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 />X <br />