HomeMy WebLinkAbout2016-12-31-YesForLexington-OCPFCommonwealth
of Massachusetts
Form CPF M 102: Campaign Finance Report
Municipal Form
Office of Campaign and Political Finance
Fill in Reporting Period dates)
Beginning Date:
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File with: City or Town Clerk or Election Commission
Ending Date:
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Type of Report: (Check one)
0 8th day preceding preliminary ❑ 8th day preceding election ❑ 30 day after election [year -end report 0 dissolution
Candidate Full Name (if applicable)
Office Sought and District
Telephone Number (optional):
Residential Address
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Committee Name
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Name of Committee Treasurer
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Committee Mailing Address
Telephone Number (optional):
SUMMARY BALANCE INFORMATION:
Line 1: Ending Balance from previous report
Line 2: Total receipts this period (page 3, line 1 I)
Line 3: Subtotal (line 1 plus line 2)
Line 4: Total expenditures this period (page 5, line 14)
Line 5: Ending Balance (line 3 minus line 4)
Line 6: Total in -kind contributions this period (page 6)
Line 7: Total (all) outstanding liabilities (page 7)
Line 8: Name of bank(s) used:
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Affidavit of Committee Treasurer;
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
activity, including all contributions, loans, receipts, expenditures, disbursements, in -kind contributions and liabilities for this reporting period and represents the campaign
finance activity of all persons acting under ht ea'ty or on behalf of this committee in accordance with the requirements of M.G.L. c. 55.
Signed under the penalties of perjury: (Treasurer's signature) Date:
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FOR CANDIDATE FILINGS ONLY: Affidavit of Candidate: (check 1 box only)
Candidate with Committee and no activity independent of the committee
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
activity, of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.i.. c. 55. I have not received any conhibutions,
incurred any liabilities nor made any expenditures on my behalf during this reporting period.
Candidate without Committee OR Candidate with independent activity filing separate report
ci 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 activity, including contributions, loans, receipts, expenditures, disbursements, in -kind contributions and liabilities for this reporting period and represents the
campaign finance 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.
Signed under the penalties of perjury: (Candidate's signature) Date:
SCHEDULE A: RECEIPTS
M.G.L. c. 55 requires that the name and residential address be reported, in alphabetical order, for all receipts over $50 in a calendar
year. Committees must keep detailed accounts and records of all receipts, but need only itemize those receipts over $50. In addition, the
occupation and employer must be reported for all persons who contribute $200 or more in a calendar year.
(A "Schedule A: Receipts" attachment is available to complete, print and attach to this report, if additional pages are required to
report all receipts. Please include your committee name and a page number on each page.)
Date Received
Name and Residential Address
(alphabetical listing required)
Amount
Occupation & Employer
(for contributions of $200 or more)
Line 9: Total Receipts over $50 (or listed above)
Line 10: Total Receipts $50 and under* (not listed above)
Line 11: TOTAL RECEIPTS IN THE PERIOD
<— Enter on page 1, line 2
* If you have itemized receipts of $50 and under, include them in line 9. Line 10 should include only those receipts not itemized above.
Page 2
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Line 9: Total Receipts over $50 (or listed above)
Line 10: Total Receipts $50 and under* (not listed above)
Line 11: TOTAL RECEIPTS IN THE PERIOD
<— Enter on page 1, line 2
* If you have itemized receipts of $50 and under, include them in line 9. Line 10 should include only those receipts not itemized above.
Page 2
SCHEDULE B: EXPENDITURES
M.G.L. c. 55 requires committees to list, in alphabetical order, all expenditures over $50 in a reporting period. Committees must keep
detailed accounts and records of all expenditures, but need only itemize those over $50. Expenditures $50 and under may be added together,
from committee records, and reported on line 13.
(A "Schedule B Expenditures" attachment is available to complete, print and attach to this report, if additional pages are required to
report all expenditures. Please include your committee name and a page number on each page.)
Date Paid
To Whom Paid
(alphabetical listing)
Address
Purpose of Expenditure
Amount
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Line 12: Total Expenditures over $50 (or listed above) 1311 n
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Line 13: Total Expenditures $50 and under* (not listed above)
Line 14: TOTAL EXPENDITURES IN THE PERIOD 1W1-11
* If you have itemized expenditures of $50 and under include them in line 12. Line 13 should include only those expenditures not itemized
Page 4
above.