HomeMy WebLinkAboutStatement of OrganizationForm CPF M101: STATEMENT OF ORGANIZATION
CANDIDATE'S COMMITTEE
MUNICIPAL FORM
Commonwealth Office of Campaign and Political Finance
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of Massachusetts
File with: City / Town Clerk or Election Commission
NOTICE IS HEREBY GIVEN in accordance with the provisions of General Laws, Chapter 55, as amended, of the organin of
candidate's committee as follows
CANDIDATE: Full Name:
Residential Address:
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City / State / Zip: j a/"
E -Mail Address:, Phone #:A I
(If applicable)
Party Affiliation:
OFFICE SOUGHT/PURPOSE:
Title:
District:
COMMITTEE: Name of Committee:
Committee Mailing Address:
City / State / Zip:
OFFICERS:
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(The name of the committee must include the candidate's last name)
Chairman: LAA4% y_j-( I
Residential Address:
City / State / Zip:
Phone #: a (�
Other Officer/Title:
Residential Address:
City / State / Zip:
Treasurer*: r(_� r)
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Residential Address: �— (�Q� 1� (iiil !+ r
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City / State / Zip: , Yl r t n �a j
Phone tg_�S•.i'� Email• Qen Pu4 dd? C'��Iant- c,(�a� •G^
Other Officer/Title:
Residential Address:
City / State / Zip:
Phone #: I Phone #: I
(Complete and attach a Form CPF M A 101, if necessary, with other officers and finance committee �f any.)
I hereby consent to the filing of this committee. I understand that a candidate shall not give consent to the organization of more than one committee on his/her
behalf. I am aware that candidates are required to keep detailed accounts and records of all campaign finance activity for a period of six years from the date of
the relevant election.
SIGNED UNDER THE PENALTIES OF PERJURY: Date: 3
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4a date's signature
I hereby accept the office of Treasurer of the above-named committee. I affirm that I am not a public employee as defined by M.G.L. c. 55, s. 13. I understand
that: 1) I am subject to certain duties and liabilities under M.G.L. c. 55, including the timely filing of campaign finance reports and keeping detailed accounts
and records of all campaign finance activity for a period of six years from the date of the relevant election; 2) if after my acceptance of this office I become an
appointed public employee, I must resign this position and notify OCA of my resignation; and 3) a candidate may not serve as treasurer of the political
committee organized on his/her behalf. '
SIGNED UNDER THE PENALTIES OF PERJURY: Date:
I hereby accept the office of Chairman of the above-named commilee.
SIGNED UNDER THE PENALTIES OF PERJURY: v
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