The URL can be used to link to this page

Home My WebLink AboutColleen for PA - 2021 2nd Friday Pre-Primary fjfPennsylvania 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 Mir 6 `e e Reporting Cycle Name ❑ Cycle 1 xi Cycle 2 ❑ Cycle 3 ❑ Cycle 4 ❑ Cycle 5 6th Tuesday 2"d Friday 30 Day 6th Tuesday 2"d Friday Pre-Primary Pre-Primary Post Primary Pre-Election Pre-Election ❑ Cycle 6 ❑ Cycle 7 ❑ Cycle 8 El 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. 05/0 S170 Signature of Treasurer, Caannd_idate, or Lobbyist Date (DD/MM/YYYY) 6Ccre(if/t-fo Printed Name Location (City/State ountry) DSEB-5035 Updated 1/22/2020 Pennsylvania Department of State "^} www.dos.pa.govBureau of Campaign/campaignfinance Finance&Civicra s Engagement 210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4) tcampaignfinance@pa.eov Part II - If this is submitted with a statement in lieu of full report by a Candidate's Authorized Committee, candidate 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. OS— bS" 0 Signature of Candidate Date (DD/MM/YYYY) Lc Il E-e,-) 6--04- A6(i yen ra t& , PA , U- 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 10 2 �l)7 y (/l h I ON BEHALF OF ► CANDIDATE COMMITTEE /1 LOBBYIST NUMBER (/ ' NAME OF G COM E,CANDIDATE OR LOB MIST /: 74 STREET RESS /-1 5d JOT 54 c r,P pire - CITY STATE ZIP ODE ito (a.____- 1C7D ._- TYPE OF REPORT N E OF OFFICE SOUGHT BY CANDIDATE , DISTRICT NO. PARTY DATE OF ELECTION (CHECK ONE) c•j 5cic.-�, 0Ae-I it- i // (� b M!O.. DAY YEAR 6TH TUESDAY7. C��tev li' � �1 -�'�'L 1 J l(`/� `( PRE-PRIMARY _J FOR OFFICE USE ONLY MO. _DAY YEAR MO. DAY YEAR 2ND FRIDAY 2. DATES OF PRE-PRIMARY A. PERIOD REPORTING 24TO .5---3 2.1 30 DAY 3. I,„y; -... Wiw POST-PRIMARY r..0 .....w. CASH BALANCE AT END 6TH TUESDAY 4' OF REPORTING PERIOD: $ 0r-` I PRE-ELECTION - 'F_ TOTAL AMOUNT OF FILER'S 2ND:FRIDAv 5' OUTSTANDING DEBTS OR LIABILITIES 7) PRE-ELECTION AT THE END OF REPORTING PERIOD: $ C) .:a s. 0 ._ 30 DAY AMENDMENT POST-ELECTION -�- REPORT? YES NO 7. ANNUAL TERMINATION REPORT REPORT? YES NO i 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 LIABIUTIES INCURRED DURING THE REPORTING PERIOD INDICATED ABOVE DID NOT EXCEED TWO HUNDRED AND FIFTY DOLLARS($250,00)AND THIS REPORT IS,TO THE BEST O . KNOWLEDGE AND B LIEF,TRUE, RRECT AND COMPLETE. SWORN TO AND SUBSCRIBED BEFORE ME THIS /r/ DAY OF 20 IGNAT E O P SUB NG REPORT SIGNATURE PRINTED NAME /l MY COMMISSION EXPIRES - MO. DAY YR. ZELCZE- T/ �ONE N R PARTII- If statement is filed on behalf of a Candidate's Authorized Committee,Candidate must sign here. I SWEAR(OR AFFIRM)THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF 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 (T. /,n SIGNATURE/ OF CANDIDA e .-._.- DAY OF _.. 20 Odle e ) `� �i3�e 1 PRINTS ME SIGNATURE I-1 q 7 9— 3-7 - / MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NUMBER MO. DAY YR. Department of State • Bureau of Commissions,Elections and Legislation DSES-503 02-99) 210 North Office Building • Harrisburg,PA 17120.0029 • (717)787-5280