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Home My WebLink About2017-12-31-Hai-OCPFForm CPF M 102: Campaign Finance Report Municipal Form Office of Campaign and Political Finance Commonwealth �f Moecarhucntte File with: Citv or Town Clerk or Election Commission Fill in Reporting Period dates: Beginning Date: 11/08/2017 Ending Date: 12/31/2017 Type of Report: (Check one) ❑ 8th day preceding preliminary ❑ 8th day preceding election ❑ 30 day after election ® year-end report ❑ dissolution Jill I. Hai Candidate Full Name (if applicable) Selectman Lexington, MA Office Sought and District 6 Highland Avenue, Lexington, MA 02421 Residential Address Telephone Number (optional): (781) 862-3776 SUMMARY BALANCE Line 1: Ending Balance from previous report gill Hai for Selectman I Committee Name Jodi R. Galin Name of Committee Treasurer PO Box 248, Lexington, MA 02420 Committee Mailing Address Telephone Number (optional): 1 (781) 910-4681 Line 2: Total receipts this period (page 3, line 11) I:joe 3: Subtotal (line 1 plus line 2) Lilpe 4: Total expenditures this period (page 5, line 14) Line 5 ding Balance (line 3 minus line 4) �® o 2,430 2,430 260.89 2,169.11 Line &-Idtal in-kind contributions this period (page 6) I 82I Line 7: Total (all) outstanding liabilities (page 7) � 0 Line 8: Name of bank(s) used: citizens Bank IfBdavit of Committee Treasurer: 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 ctivity, including all contributions, loans, receipts, expenditures, disbursements, in-kind contributions and liabilities for his reporting period and represents the campaign finance activity of all persons acting under the only or onjbchat this room ltee in accordance with the requirements of M.G.L. e. 55. signed under the penalties of perjury: �/ 1 - //% (Treasurer's signature) Date: 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 Ractivity, 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, 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 E]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 al I campaign finance activity, including contributions, loaV, receipts, expenditures, disbursements, in-kind contributions and liabilities for this reporting period and represents the campaign finance activity of all persons aefifg under the authority wit+4 utirof this committee in accordance with the requirements of M.G.L. c. 55. under the penalties of perjury: 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 ofall 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 1/15/2017 11/26/2017 12/16/2017 11/30/2017 12/16/2017 Vame and Residential Address Occupation & Employe (alphabetical listing required) I Amount (for contributions of $200 or wczyk,John Outlook Drive :inoton. MA 02421 Piltch, Cynthia 18 Barberry Road Lexinaton. MA 02421 Silberstein, John 1199 Park Avenue New York, NY 10128 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 itemized receipts Health Educator 125 Boston University Center for Psychiatric Rehabilitation / Investor 1,000 2,430 CO 2,430 F Enter on page I, line 2 9. Line 10 should include only those receipts not itemized above. Page 2 Jodi R. psychologist rGalin, 5 Fletcher Avenue Leixngotn, MA 02420 100 Jodi R. Galin, Ph.D. Gens, Marcia Dane Road 50 Lexington, MA 02421 Le Hai, Jill ppst- V\" 6 Highland Avenue Lexington, MA 02421 ��11 z,]ame BarberRoad MA 02421 r 125ington, General Counsel Beth Israel Deaconess Hospital wczyk,John Outlook Drive :inoton. MA 02421 Piltch, Cynthia 18 Barberry Road Lexinaton. MA 02421 Silberstein, John 1199 Park Avenue New York, NY 10128 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 itemized receipts Health Educator 125 Boston University Center for Psychiatric Rehabilitation / Investor 1,000 2,430 CO 2,430 F Enter on page I, line 2 9. Line 10 should include only those receipts not itemized above. Page 2 SCHEDULE A: RECEIPTS (continued) Date Received Name and Residential Address (alphabetical listing required) Amount Occupation & Employer (for contributions of $200 or more) I F O m � Line 9: Total Receipts over $50 (or listed above) F Enteron page 1, line 2 Line 10: Total Receipts $50 and under* (not listed above) Line 11: TOTAL RECEIPTS IN THE PERIOD * 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 3 SCHEDULE B: EXPENDITURES M.G.L. c. 55 requires committees to list, in alphabetical order, all expenditures over $50 in a reportingperiod 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 re ort all expenditures Please include your committee name and a page number on each page.) P To Whom Paid Date Paid (alphabetical listing) Address Purpose of Expenditure Amount Loves Buttns, Inc. r248251N 16th Avenue12/21/2017Everyone 0Cmpaign ButtonsAZ 85085 Reimburse for 1+1 Internet 12/11/20Y7 FKrawczyk, ]ohn 78 Outlook Drive Lexington, MA 02421 Website invoice #202018930877 22.33 11/30/2017 PayPal t North Firs7CA San lose, [Service Fee 1.77 --7 12/23/2017 Vistaprint Vistaprint Netherlands BV Hudsonweg 8 lVenlo, Business cards 46.74 L The Netherlands 5928LW 7F 11 L- I F I L-- Line 12: Total Expenditures over $50 (or listed above) 260.89 Line 13: Total Expenditures $50 and under* (not listed above) Enter on page 1, line 4 Line 14: TOTAL EXPENDITURES IN THE PERIOD 260.89 * If you have itemized expenditures of $50 and under, include them in line 12. Line 13 should include only those expenditures not itemized above. Page 4 SCHEDULE B: EXPENDITURES (continued) Date Paid To Whom Paid (alphabetical listing) Address Purpose of Expenditure Amount Ver :11 F - IF 1 11 L l 1 17:1. Line 12: Expenditures over $50 (or listed above) Line 13: Expenditures $50 and under* (not listed above) Line 14: TOTAL EXPENDITURES IN THE PERIOD Enter on page 1, line 4 * If you have itemized expenditures of $50 and under, include them in line 12. Line 13 should include only those expenditures not itemized above. Page 5 SCHEDULE C: "IN-KIND" CONTRIBUTIONS Please itemize contributors who have made in-kind contributions of more than $50. In-kind contributions $50 and under may be added together from the committee's records and included in line 16 on page 1. Date Received From Whom Received* Residential Address Description of Contribution Value 11/10/2017 Galin, Jodi R. 5 Fletcher Avenue F3months t Office Box 82 Lexington, MA 02420 n n Line 15: In -Kind Contributions over $50 (or listed above) Line 16: In -Kind Contributions $50 & under (not listed above) Enter on page 1, line 6 - ( Line 17: TOTAL IN -HIND CONTRIBUTIONS * If an in-kind contribution is received from a person who contributes more than $50 in a calendar year, you must report the name and addres< of the contributor; in addition, if the contribution is $200 or more, you must also report the contributor's occupation and employer. page 6 SCHEDULED: LIABILPI`IES M.G.L. c. 55 requires committees to report ALL liabilities which have been reported previously and are still outstanding, as well as those liabilities Incurred during this reporting period. Date Incurred To Whom Due Address Purpose Amount r I F F Enter on page I, line 7 Line 18: TOTAL OUTSTANDING LIABILITIES (ALL) Page 7