HomeMy WebLinkAboutFish, David - 2021 2nd Friday Pre-Primary Pennsylvania Department of State
Bureau of Campaign Finance&Civic Engagement
210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4)
www.dos.pa.gov/campaignfinance • ra-stcampaignfinance@pa.gov
Unsworn Declaration in Lieu of Sworn Statement for
Campaign Finance Statements
Note: Per Act 2020-15, which was signed into law on April 20, 2020 and allows for unsworn
declarations, Campaign Finance Reports (form DSEB-502), Campaign Finance Statements in lieu
of full reports (form DSEB-503), Non-Bid Contract Reporting Form (DSEB-504) and Independent
Expenditure Reports (form DSEB-505) need not be notarized. Instead, the filer may file with each
report or statement the corresponding version of this form signed by the required individual(s).
This particular form is to be used only for Campaign Finance Statements. This form must be
signed by hand where a signature is required.
Name of Filing Committee, Candidate, or Lobbyist
David J. Fish
Reporting Cycle Name
❑ Cycle 1 Cycle 2 ❑ Cycle 3 ❑ Cycle 4 ❑ Cycle 5
6th Tuesday 2nd Friday 30 Day 6th Tuesday 2nd Friday
Pre-Primary Pre-Primary Post Primary Pre-Election Pre-Election
❑ Cycle 6 ❑ Cycle 7 ❑ Cycle 8 ❑ Cycle 9
30 Day Post-Election Annual Report 2"d Friday Pre-Special Election 30 Day Post-Special Election
Part I — If this form is submitted with a statement in lieu of full report by a political
committee, the treasurer must sign here. If this form is submitted with a statement in lieu
of a full report by a candidate, the candidate must sign here. If this form is submitted with
a statement in lieu of full report by a contributing lobbyist, the lobbyist must sign here.
I declare under penalty of perjury under the law of the Commonwealth of Pennsylvania
that the accompanying Campaign Finance Statement is true and correct.
OCAAJj 05/05/2021
Signature of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY)
David J. Fish Hampden Township/PA/USA
Printed Name Location (City/State/Country)
DSEB-503S
Updated 1/22/2020
COMMONWEALTH OF PENNSYLVANIA
CAMPAIGN FINANCE STATEMENT
File this in lieu of a full report only if aggregate receipts, expenditures, or
liabilities incurred each did not exceed $250.00 during the reporting period.
FILER IDENTIFICATION REPORT FILED ttf�����,
NUMBER , ON BEHALF OF01,
CANDIDATE JC COMMITTEE LOBBYIST
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIS !`
STREET ADDRESS
Li4S L&M,,p QU if LAJ
CITY STATE ZIP CODE
C0-AA.V 11-t1I ?
jFl t�U 11 - i `ia-�'
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE {DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) "t`r),,�te COMM s Id_`e' ` ` f MO. DAY YEAR
6TH TUESDAY 1 TV 'V L '-1 !11 MC rithC 0 S )$ a„1
PRE-PRIMARY FOR OFFICE USE ONLY
MO. DAY YEAR MO. DAY I YEAR
2ND FRIDAY 2\/ DATES OF
PRE-PRIMARY X REPORTINGPERIOD 0 3 30 )0�1 TO Os 3 aa�'
`
30 DAY 3
POST-PRIMARY ," fi'w
CASH BALANCE AT END O CZ
om`
6TH TUESDAY 4 OF REPORTING PERIOD: $
PRE-ELECTION r n I J,E
TOTAL AMOUNT OF FILER'S - --+:
5. OUTSTANDING DEBTS OR LIABILITIES O
2ND FRIDAY I
PRE-ELECTIONAT THE END OF REPORTING PERIOD: $ Cis
C3
6. C)
30 DAY AMENDMENT
POST-ELECTION REPORT? YES NO
ANNUAL TERMINATION 'y/ ..+.4 I�
REPORT REPORT? YES NO /� C,rl
AFFIDAVIT SECTION
PART I-
If statement is filed on behalf of a Political Committee or Candidates's Committee,the Treasurer must sign here.
If statement is filed on behalf of a Candidate,the Candidate must sign here.
If statement is filed on behalf of a Contributing Lobbyist, the Lobbyist must sign here.
I SWEAR(OR AFFIRM)THAT THE AGGREGATE RECEIPTS OR DISBURSEMENTS OR LIABILITIES INCURRED DURING THE REPORTING PERIOD INDICATED ABOVE DID NOT
EXCEED TWO HUNDRED AND FIFTY DOLLARS(S250.00)AND THIS REPORT IS,TO THE BEST OF MY KNOWLEDGE Kum',TRUE,CO ,ECT AND COMPLETE..
SWORN TO AND SUBSCRIBED BEFORE ME THIS /
DAY OF 20 \ SIGNATURE OF RSON SU MITTING REPORT
PRINTED NAME SIGNATURE _
L l,) [ 3? - b G S
MY COMMISSION EXPIRES
MO. DAY YR. AREA CODE DAYTIME TELEPHONE NUMBER
PART II -
if statement is filed on behalf of a Candidate's Authorized Committee, Candidate must sign here.
I SWEAR(OR AFFIRM)THAT TO THE EEST OF MY KNOWLEDGE AND SELIE.THIS POLITICAL.COMMITTEE HAS NOT VIOLATED ANY PROVISIONS OF THE ACT OF
JUNE 3, 1937(P.L. 1333.No.320)As AMENDED.
SWORN TO AND SUBSCRIBED BEFORE ME THIS
SIGNATURE OF CANDIDATE
DAY OF 20____
PRINTED NAME
SIGNATURE
MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NUMBER
MO. DAY YR.
Department of State • Bureau of Commissions,Elections and Legislation
DSG13-503(12.99) 210 North Office Building • Harrisburg,PA 1712040029 • (717)787-5280