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HomeMy WebLinkAboutFriends of David Fish - 2021 2nd Friday Pre-Primary Pennsylvania Department of State Bureau of Campaign Finance&Civic Engagement 1...._17 210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4) • 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. FR.IEA/b5 ©F nM vD F W D Cycle 1 ld Cycle 2 0 Cycle 3 0 Cycle 4 ❑ Cycle 5 6th Tuesday 2nd Friday 30 Day 6th Tuesday 2nd Friday Pre-Primary Pre-Primary Post Primary Pre-Election Pre-Election 0 Cycle 6 0 Cycle 7 ❑ Cycle 8 0 Cycle 9 30 Day Post-Election Annual Report 2nd 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. !f 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. �4PC;i21 7 , v51 087d oR f Signature of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY) ((444t OE n/ TAN s14-'' ) 6--re ✓y G, 6-`a✓cC / $GhGn IG shoel / PA n Printed Name Location (City/State/Country) DSEB-503S Updated 1/22/2020 Pennsylvania Department of State ,r Bureau of Campaign Finance&Civic Engagement •y 210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4) Part n - 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. S705/?'d?-/ Signature of Candidate Date (DD/MM/YYYY) Fi5/\ TuiP/P4--/ (4J/4/- Printed Name Location (City/State/Country) OSEB-5035 Updated 1/22/2020 COMmONWEALTv OF PENNSYL;ANIA. 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, REPORT FILED Op I CANDIDATE `CO'.hITE I E l LOBBYIST NUMBER ON B'cHALF OF — VVV j r NAME OF RUNG COMMtTES.CANDIDATE OR LDSr`:[ST F,QJ AIo5 of oAUTD f.1 1 STREET ADDPESS L05 L,4/7P %05r L 4.ivC CITY G AMP !/ ,E��' STATE P 1 R ZIPCODE7e11 1 u2 { TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE !DISTRICT NO. PARTY DATE.'OF ELECTION.'-, (CHECK ONE) --�" )) �t /' ! j MO. I DAY I YEAR 1JWnSh1Y Amin s‘iora cy-- 9atJa�'iG ! OS 18 anal 6TH TUESDAY 1 t / PRE-PRIMARY IFOR OFFICE USE ONLY MO. DAY I YEAR 1 '.AO. DAY• ' YEAR 2 DATES OF 1 It --- 2ND FRIDAY • PRE-PRIMARY 1 / REPORTING Ida s p) i p / 1 TC 03 03 031 VV PERICD so Gti A� ) 30 DAY `' C? Pr..., POST-PRIMARY I. C-- om^' i CASH BALANCE AT END ,/ / a;. OF REPORTING PERIOD: " i 6 6TH'TUESDAY a `u n PRE-ELECTION I '.- ! TOTAL AMOUNT OF FILER'S .�,,. I.M 2ND FRIDAY 1 5. I OUTSTANDING DEBTS OR LIABILITIES •Q o'i PRE-ELECTION 1 AT THE END OF REPORTING PERIOD: S Q..c)a ! I µ 30 DAY b f s9 POST-ELECTION REPAMORT? - NO1/ t ANNUAL TERMINATION YES NO ! J REPORT I, REPORT? 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. It statement is filed on behalf of a Contributing Lobbyist, the Lobbyist must sign here. 4 I S...'E.. (OR .A. tR ')THAT THE AGGREGATE PECE P-S E , -S'.RS_.E ES R D ., :. E REPO -N `>E:O:OlO GATED A 3',E_r;0 NOT f EASED .,i3 HUNDRED AND FiETY G'C.... (S25U.00 I-_ .-.RE _ S. .,THE HES" ,= LEE _;.P. TRUE. CORRECTCOR,REC-T Ar IL. .....R_. _. r�/�f�,�' ( SWORN TO AND SUBSCRIBED BEFORE ME THIS `--��ry����� "'���y�1yr7 ------'���G'/,-/-"� --- I t DAY OF 20 SIGNATURE OF PERSON SUBMITTING REPORT 1 rr a/'y C- vo7--F1 ; SIGNATURE J PRINTED NAME�7 MY COMMISSION EXPIRES -717 _ 7q'-p 31/ i MO. DAY YR. AREA CODE DAYTIME TELEPHONE NUMBER i I PART II - If statement is filed on behalf of a Candidate's Authorized Committee, Candidate must sign here. SWEAR(OR -_-4;)THAT TO THE EiES J' . ..._.._F_v=AltO EEL -✓_-C _ _,•. .. EE HAS NOT -ICLATYD A•,."; FAG.'tS-OHS OE THE ACT OF i 3. i 9 37(P.I_. 13T3 -:. 320i = •..5._55. 1 J SWORN TO AND SUBSCRIBED BEFORE ".ETHiS _ I t -IGNATURE,OF CANDIDATE OA'i OF 20 r I _Cl/LD J - Pis( PRINTED NAME �. R SIGNATURE ') [-i > ' ( 3,5 I I MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NUMBER MO. DAY YR. Department of State • Bureau of Commissions.Elections and Legislation DM_I:; r13{t,_,t,i _ 210 North Office Building • Harrisburg,PA 17120-0029 • (171 7&7-.52 0