HomeMy WebLinkAbout2011-12-31-Burnell-OCPFForm CPF M 102: Campaign Finance Report
Municipal Form
Office of campaign and Political Finance
File with
City or Town Clerk or Election Commission
Please print or type all information, except signatures.
Fill in dates: Yet Month Dets Yew
Reporting Period Beginnin r 6 . k� t d Ending 1 "�> t 9- u l!
Type of report: (Check one) ��°
08th day preceding preliminary' 08th day preceding election 030 day after election -0-year -end report 0dissolution
Full m of Candldate (if applicable)
( VVVNA
Office sought and District
Y1 ® r'�
Residential Address
Tel. No. (optional)
C S , ^ a 1 j IL /n
!� Committee Name
1° r e' rA in -:. -o
Name of Commi tee Treasurer
Committee Mailing Address 0 >0 �
Tel. No. (optional)
SUMMARY BALANCE INFORMATION:
$ , i C i
$
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)
Line 5: Ending balance (line 3 minus line 4)
$
S IL 1.C-(
Line 6: Total in -kind contributions this period (page 4) S
Line 7: Total (all) outstanding liabilities (page 4) $ � `
d
Line 8: Name of bank(s) use �`t �� k-
AfAdavit of Committee Tressumr.
period I certify that I have examined this report including attached schedules and it i4 to the bas of my o knowledge and belief; a true and compile statement of alt eampahe
Srnaom act including all contributions, loam, receipts, ex pmdiWra. disbursernents, in kn►d ccontributions and liabilities for shier rcportirrg p perod and represents t
campaign finance activity o dtpersons acting under the authority or on behalf of this co n nittee in accordance with the requimnients of M.G.L. c. 33.
Signed under the penalties of perjury:
sign um (in
FOR CANDIDATE FILINGS ONLY (CANDIDATE MUST SIGN BELO
AMOA of Gn411d2te: (check 1 box only)
P , Cnnd IdMe with Coamnittee and two aetMty independent of the committee lda statemerd of all campaign
I certify that I have examined this report inchrd:ng attadned 'W and it is, to the bed of my knowledge and belief a true and comp
tnrnar►ce activity, of all persons acting under tt+e authority or on behalf of this oommittee in accordance with the requirements of M.G.L c. SS. I have not received any
cootributiom, .1.,d any liabilities nor gads ary apuditt— - my behalf dring this repor ing peno
❑ car ,didate (without Committee OR Candidate with Independent activity !flint separate report
I certify that 1 have etrarnirwcd this report incin:::'. g attached scbedula and it is, to the best of my knowledge and belief ; A true and eortglde staternernt of all pmpaign
ex
finance activity, including Contributions, loaner, receipts patditurea, dislnurse:rnanfs, m ku:d contribution and liabilities for this reporting period and represents the
campaign fnw►ce 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.
/� /7 / f Signed under the penalties of perjury: / /.- y
'Dam
signature (in ink) -
SCHEDULE C: "IN- KIND" CONTRIBUTIONS
Please itemize contributors who have made in -kind contributions of more than $50. In -kind conttiib�tibns'$C4 be
added together from the committee's records and included in line 16.
Date
Received
From Whom Received*
Residential Address
Description lot ' , ,.x
Contribution
� VAllue
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)
1.
This page may be copied if additional pages are required to report all activity. Please include your committee name and a page
number on each page. `a printed an recycled paper Page 4