HomeMy WebLinkAbout2010-12-31-Burnell-OCPFForm CPF M 102: Campaign Finance Report i"*; E I V
Municipal Form
Gmce of campaign and Political F7nance 201 J, — 4 AM 8 : 4 6
.rM` t. TO W Pi
LtXI �u T ON H
File with:
City or Town Clerk or Elation Conwtission
Please print or tvoe all information, except signatures.
Fill in dates: Month Date Year
Month Date Yew
Reporting Period Beginning_C� `z+ `� (., 1 u Ending I ',;( S ( ";In, 3
Type of report: (Check one)
08th day preceding preliminary 08th day preceding election 030 day after election 2`year -end report ❑dissolution
Full Name of Candidate (if applicable)
Office Sought and District
Residential Address
Tel. No. (optional)
Tel. No. (optional)
SUMMARY BALANCE INFORMATION:
Line 1: Ending balance from previous report $
Line 2: Total receipts this period (page 2 line 11) $
Line 3 : Subtotal (line 1 plus line 2) $
Line 4: Total expenditures this period (page 3, line 14) $ b
Line 5: Ending balance (line 3 minus line a) $ ) i
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Line 6: Total in -kind contributions this period (page a) $ C
Line 7: Total (all) outstanding liabilities (page a) $ S `1 , ;VU
Line 8: Name of bank(s) use ) 4ki— L--
Affidavit of Cmmnnittee Treasurer.
I certify that 1 have examined this report including attached sche&les and it is, to the best of my knowledge and belief, a true and complete statement of all ampa:gn
finance activity, including all contributions, loans, receipts, exPerditures, disbursements, tit." contributions and liabilities for this reporting Period and represents the
campaign f of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. o, 5
Signed under the penalties of perjury: l t
signature (in ink)
FOR CANDIDATE FILINGS ONLY (CANDIDATE MUST SIGN BELOW)
Af 11 vit of Candidate: (check I box only) of the committee
andidate with Committee and no activity independent
I catify that I have examined this report including attached schedules and it is to the best of my knowledge and belied a true and complete s 1 have 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.L a SS. I have not received any
contributions, marred any liabilities nor made any expenditures on my behalf during this reporting period.
Candidate without Commtttea OR Candidate with Independent activity filing separate report
I certify that I have examined this report including attached schxdules and it is, to the best of my knowledge and belief; awe and complete statement of all campaign
finance activity, including contributions, loans, rcoetpts, expenditures, d:sbursemcttts, in-kind contributions and liabilities for this reporting period and represents the
campaign fmanceactivity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G..l- c. SS.
A2 s Signed under the penalties of perjury: ( / f / /� 0
U Committee Name
Name of Committee Treasurer
� . Committee Mailing Address 6SL al
4-- - (- 5 - ") k 1 4Y t/
Date
signature (in ink)
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
" _J . _.t a.......t6. . .nittc tc rnrnrttc anti inrhirlpA in line 16.
auuw tur
Date
uvau
From Whom Received*
Residential Address
Description of
Value
Received
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Cord
Contribution
N
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=-
LIABILITIES (ALL)
, cM ♦or nn na OP. t line 7
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Line 15: In -kind over $50
Line 16: In -kind $50 and under
Line 17: Total In -kind
F.ntPr nn naQe 1. line 6
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* 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 address of the contributor; in addition, if the contribution is $200 or more, you must also report the contributor's occupation and
employer.
SCHEDULE D: LIABILITIES
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 To Whom Due
Incurred
Address
Purpose
Amount
_.
Cord
Line 18: OUTSTANDING
LIABILITIES (ALL)
, cM ♦or nn na OP. t line 7
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This page may be copied if additional pages are required to report all activity. Please include your committee ge d a page
number on each page. " printed on recycled paper