HomeMy WebLinkAbout2011-04-07-Embry-OCPFForm CPF M 102: Campaign Finance Report
Municipal Form
A a utieal Fhnance o f
.�. Vince of Campaign an o ri A R
of Ma adu.an r '
File with:
City or Town Cleric or Election Commission 1� )'���
Please print or type all information, except signatures.
Fill in dates: Maur Due v et Month DW yen
Reporting Period Begin / / Ending ' :� f I f
Type of report: (Check one)
❑8th day preceding preliminary 08th day preceding election 30 day after election ❑year -end report ❑dissolution
.,
Full Name of Candidate (if applicable)
Office Sought and District
Residential Address
Tel. No. (optional)
Committee Name
Name of Committee Treasurer
Committee Mailing Address
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) $_ 0
Line 4: Total expenditures this period (page 3 line 14) $ C) _
Line 5: Ending balance (line 3 minus line 4) $ —C)
----------------------------------
Line 6: Total in -kind contributions this period (page 4) $
Line 7: Total (all) outstanding liabilities (page 4) $
Line 8: Name of bank(s) used
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
flounce activity, including all contributions, loans, receipts, expenditures, disbursements, k 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. 33.
Signed under the penalties of perjury:
Treasurer's siputure (in ink) Date
FOR CANDIDATE FILINGS ONLY (CANDIDATE MUST SIGN BELOW)
Affidavit of Candidate: (check I box only)
C Candidate with Committee and no activity independent of the committee
I ccr* that I have examined this report including attached schedules and it is, to the best of my knowledge and belie; 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.L. c. SS. I have not received any
contributions, incurred any liabilities nor made any expenditures on my behalf during this reporting period.
O Candidate without Committee OR Candidate with Independent activity thing separate report
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 statem A of all campaign
finance activity, including contributions, 1 receipts, expenditures, disbursements, in -kind contributions and liabilities for this reporting period and represents the
campaign fuu oe activity of all per:orta under the authority or on behalf of this conuruttee in accordance with the requirements of M.G.L. c. 35.
Signed under the penalties of perjury:
Candidate siowture (in ink) 11 Date
Form CPF M 102 -0: Campaign Finance Report
Municipal Form
Office of Campaign and Political Finance
Cosa�onwa116 ,
of l.buuw
City or Town of
Please print or type all information, except signatures.
Fill in dates: Month
Day Year
Month
Day
Year
f
Reporting Period Beginning
,✓
Ending
/.
Type of Report: (Check One)
8th day preceding 8th day preceding election a 30th day following election 0 20th day of January
preliminary/primary (Town or Special) ( Year -End Report)'
Pursuant to M.G.L., Chapter 55:
1. I certify that I am a candidate for or hold Municipal Office,
2. 1 certify that I have not received any contributions, made any expenditures, or incurred any obligations during this
reporting period, and do not have a campaign fund in existence.
3. I certify that I do not have a political committee.
DATE
I. SIGNATURE
Signed under the - penalties of perjury
I1. RESIDENTIAL ADDRESS
(Street and Number)
III. OFFICE SOUGHT
3
t
!!l",
CJ
SCHEDULE A: RECEIPTS
t,1,G.L. c. 55 requires that the name and residential address be reported, in alphabetical order, for all receipts
0j )er $50.in a calendar year. Committees must keep detailed accounts and records of all receipts, but need only
Niwnize those receipts over $30. In addition, the occupation and employer must be reported for all persons who
ctyltribute ,$200 or more in a calendar year.
1%js page may be copied if additional pages are required to report all receipts. Please include your committee name and a page
MIUCr Vil `.QVll
Date
teeeived
Yagv.
Name and Residential Address
(alphabetical listing required)
Amount
Occupation &Employer
(for contributions of $200 or more)
Line 9: Total receipts in excess of $50 (or listed above)
Enter on 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
Page 2
above.
SCHEDULE B: EXPENDITURES
MG. L. c. SS 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.
This page may be copied if additional pages are required to report all expenditures. Please include your committee name and a page
mimher nn each nave.
-
Date Paid
r-o
To Whom Paid
(alphabetical listing)
Address
Purpose of Expenditure
Amount
Enter on vase 1, line 4
Line 12: Expenditures over $50
Line 13: Expenditures $50 and under*
Line 14: TOTAL EXPEN DITURES
*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 3
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.
Date
Received
From Whom Received*
Residential Address
Description of
Contribution
Value
Enter on page 1, line 6
Line 15: In -kind over $50
Line 16: In -kind $50 and under
Line 17: Total In -kind
Line 18: OUTSTANDING LIABILITIES (ALL)
* 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
Incurred
To Whom Due
Address
Purpose
Amount
Enter on page 1, line 7
Line 18: OUTSTANDING LIABILITIES (ALL)
This page may be copied if additional pages are required to report all activity
number on each page. Q Aft
printed on recycled paper
Please include your committee name and a page
Page 4