HomeMy WebLinkAboutMechanicsburg Future Fund - 2021 2nd Friday Pre-Primary Pennsylvania Department of State
ftrif Bureau of Campaign Finance&Civic Engagement
210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4)
www.dos.pa.gov/camnaignfinance • ra-stcampaignfinance0pa.gov
Unsworn Statement 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), 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
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Reporting Cycle Name
❑ Cycle 1 cycle 2 0 Cycle 3 0 Cycle 4 0 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 0 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. 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 foregoing is true and correct.
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Signature of Treasurer Candidate,or Lobbyist Date (DD/MM/YYYY)
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Printed Name Location (City/State/Country)
DSEB-503S
Updated 6/24/2020
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.
PUPA IDENTHICATKTN ' REPORT FILED '
NUMRFR ON BEHALF OF CANDIDATE I COMMITTEE '� LOBBYIST
NAVE 0 FILMIC COMMITTEE,CANDIDATE OR LOBBYIST
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STREET ADDRESS
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CITY , STATE ZIP CODE
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TYPE OF REPORT NAME OF O E SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION 1
(CHECK ONE) MO. DAY 4 YEAR
6TH TUESDAY 1 - -- -- -- - - 5 1 15' k EAO2.1
PRE-PRIMARY FOR OFFICE USE ONLY
MO. DAY YEAR MO. DAY 1 YEAR 1
/ t--
2ND FRIDAY
PRE-PRIMARYREPORTING t 1 1‘ rl TO '^/.Zv`/ PERIOD F 1 _-__- � 1 'G..'' F•
30 oar 3 ,'
POST-PRIMARY 7`Q W :,,^�
CASH BALANCE AT END , ;„,
6TH TUESDAY ° OF REPORTING PERIOD: $ I,,.�. I
PREELECTION ^'" „-
TOTAL AMOUNT OF FILER'S r
2ND iRIOAY 5 OUTSTANDING DEBTS OR LIABILITIES c,
PREELECTION AT THE END OF REPORTING PERIOD: $ -. 0
B. _ ------ - -- - - 0
.,,....
-30 DAY AMENDMENT 11111111:1115
POSTELECTION REPORTS INZ- )'`,;)
ANNUAL T TERMINATION 0111:112 t....
REPORT REPORT?
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 AFFIR:I)THAT THE AGGREGATE RECEPTS OR DISBURSELIENTS 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'IV KNOWLEDGE AND BELIEF,TRUE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS r'"•'
DAY OF 20_ SIGNATURE OF PERSON SUBMITTING REAART
PRINTED NAME
SIGNATURE J
MY COMMISSION EXPIRES ' I l I'. ' , 1 2-.),•- k _
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 BEST OF IN 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
SIGNATURE OF CANDIDATE
DAY OF 20__
PRINTED NAME
SIGNATURE
MY COMMISSION EXPIRES - AREA CODE DAYTIME TELEPHONE NUMBER
NO. DAY YR.
Department of State .e Bureau of Commissions,Elections and Legislation