HomeMy WebLinkAbout2011-12-31-Kelley-OCPFForm CPF M 102: Campaign Finance Report
Municipal Form
Offlce of Campaign and Political FhuuKe
arlNaaearisaata " , ., t l� i 41 1 I f 4S. �_
File with:
City or Town Clerk or Election Commission
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kwase print or type an mrormauort, except Signatures.
Fill in dates: Month Dane Year Monthh oats ran
Reporting Period Beginning . L), (\ d C 1 - Ending ('c G i
Type of report: (Check one) //
08th day preceding preliminary 08th day preceding election 030 day after election year -end report ❑dissolution
Full Name of Candidate (if kpplicable)
a ic -w and Dist c g t °^ �,s u
Residential Address
Tel. No. (optional)
U mmt Ve-e- A0 � iglle 6 - W
, l ommittee Name
\-� . 0-11 t � t v S
Name of Committee Treasurer s "y
Committee Mailing Address
Tel. No. (optional)
SUMMARY BALANCE INFORMATION:
Line 1: Ending balance from previous report $ I G `1(o ,
Line 2: Total receipts this period (page 2 line 11)
Line 3 : Subtotal (line 1 plus line 2) $ I `t
Line 4: Total expenditures this period (page 3 line 14) $_
Line 5: Ending balance (tine 3 minus line 4) $ =�
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 Q) �,\ (\e, ?nom
Amovit 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, disbutaanarts, it 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. 35.
Signed under the penalties of perjury:
g) Qk
'reasurer's signature
M
- -�> i-
FOR CANDIDATE FMINGS ONLY (CANDIDATE MUST SIGN BELOW)
Atndavit of Candidate: (check 1 box only)
O 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 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. e. 33. 1 have not received any
contributions, incurred any liabilities nor made any expenditures on my behalf during this reporting period.
0 Candidate without Committee OR Candidate with independent activity filing 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 statement of all campaign
finamce activi contributions, loans, receipts, expeditu is, disbunnenats, in -kind contributions and liabilities for this reporting period and represents the
carnpaig<t f 7&vi of all person acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. SS.
Signed under the penalties of perjury:
Date
Candidate si[ru (in'
SCHEDULE A: RECEIPTS
14. G. L. c. 55 requires that the name and residential address be reported, in alphabetical order, for all receipts
oj ,er $50. in a calendar year. Committees must keep detailed accounts and records of all receipts, but need only
11+.'►nize those receipts over $50. In addition, the occupation and employer must be reported for all perso1ns who
C11,11ribute $200 or more in a calendar year.
, -Ills page may be copied if additional pages are required to report all receipts. Please include your committee name and a page
nmilbcr 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 in excess of $50 (or listed above)
Enter on page 1, line 2
Line 10: Total receipts $50 and under* (not listed above)
Q
Line ill: TOTAL RECEIPTS IN THE PERIOD
C)
* If you have itemized receipts of $50 and under include them in line 9
above.
Line 10 should include only those receipts not itemized
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.
This page may be copied if additional pages are required to report all expenditures. Please include your committee name and a page
niiinher nn each nave.
Date Paid
r v To Whom Paid
(alphabetical listing)
Address
Purpose of Expenditure
Amount
C
�3
Enter on page 1, line 4
Line 12: Expenditures over $50
Line 13: Expenditures $50 and under*
Line 14: TOTAL EXPENDITURES,
*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
CT
4
Enter on page 1, line 6
Line 15: In-kind over $50
(D
Line 16: In-kind $50 and under
0
d
Line 17: Total In-kind
0
* 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.
91:1 Dili 01 314"A
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)
C)
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. printed on recycled paper Page 4