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�— a Form CPF M 102-0: Campaign Finance Report
Municipal Form
.�.6� Office of Campaign and Political Finance
Commonwealth
of Mo.othr.at
City or Town of: /7/:;(1.)./. .---k
Please print or type all information,except signatures.
Fill in dates:Reporting Period Beginning Month Day Year �ILt� Day Year
Ending 0. a/)
Type of Report: (Check One)
8th day preceding 1:18th day preceding election 13 30th day following election 20th day
of
January
preliminary/primary (Town or Special) (Year-EndReport).
Pursuant to M.G.L.,Chapter 55:
I. I certify that I am a candidate for or hold Municipal Office.
2. I certify that 1 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 II. RESIDENTIAL ADDRESS III. OFFICE SOUGHT
Signed under the penalties of perjury (Street[/and Number) q T
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