HomeMy WebLinkAboutFriends of Lisa Grayson - 2021 2nd Friday Pre-Primary 1E( 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
Friends of Lisa Grayson
LReporting Cycle Name
❑ Cycle 1 L Cycle 2 ❑ Cycle 3 ❑ Cycle 4 El Cycle 5
6th Tuesday 2nd Friday 30 Day 6th Tuesday 2"d 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'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.
05/07/2021
gnature o ea rer, Candidate, or Lobbyist Date (DD/MM/YYYY)
Kyle A. Cooper Carlisle PA USA
Printed Name Location (City/State/Country)
DSEB-503S
Updated 1/22/2020
g,, 1 Pennsylvania Department of State
,4vBureau of Campaign Finance&Civic Engagement
210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4)
• www.dos.pa.gov/campaignfinance • ra-stcampaignfinancePpa.gov
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.
05/07/2021
Signature of Can:idate Date (DD/MM/YYYY)
Lisa M. Grayson Carlisle 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 $250.00 during the reporting period.
I110,
. ,FILER IbEHT1F1CAT10N , REPORT FILED CANDIDATE 1 COMMITTEE 1- 1 LOBBYIST 3
NUMBER ON BEHALF OF
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST Friends of Lisa Grayson
STREET ADDRESS PO Box 333
CITY STATE ZIP CODE - - -
Carlisle PA 17013
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) Register of Wills 21 Rep 11MO. 02 DAY
YEAR
2021 1.
6TH TUESDAY
PRE-PRIMARY FOIIOFFICE U$E ONLY
MO. I DAY YEAR MO. DAY YEAR �- _ --- ---
2ND FRIDAY 2. DATES OF
PRE-PRIMARY X REPORTING 01 01 21 TO 05 03 21 toy ..:�.
PERIOD
r-r'I 3
30 DAY 3' -
POST-PRIMARY i
CASH BALANCE AT END 0 = --.1
6TH TUESDAY 4. OF REPORTING PERIOD: $ a
PRE-ELECTION C) 'r
TOTAL AMOUNT OF FILER'S 0
2ND FRIDAY 5. OUTSTANDING DEBTS OR LIABILITIES 22,650.63 C N
PRE-ELECTION AT THE END OF REPORTING PERIOD: $ -4 Cu`t
..< .....16.
30 DAY AMENDMENT
POST-ELECTION REPORTS YES ❑ NO El
7.
ANNUALTERMINATION YES ri NO
REPORT REPORT?
AFFIDAVIT SECTION
PARTI-
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.O0)AND THIS REPORT IS,TO THE BEST OF MY KNOWLEDGE AND BELIEF,TRUE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS Kyle A. Cooper Digitally signed by Kyle A.Cooper
Y P Dale:2021.05.07 13:06:48-0400
DAY OF 20 SIGNATURE OF PERSON SUBMITTING REPORT
Kyle A.Cooper
SIGNATURE PRINTED NAME
MY COMMISSION EXPIRES 717 422-4457
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 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 Lisa M. Grayson Oote:2Digitally signed by Lisa 58:4 -0Gr4yspn
Y Dale:zozl.os.o71z:5s:4z-04no
SIGNATURE OF CANDIDATE
DAY of 20_ Lisa M.Grayson
PRINTED NAME
SIGNATURE 717 580-1254
MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NUMBER
MO. DAY YR.
Department of State • Bureau of Commissions,Elections and Legislation
DSLD-503(12-99) 210 North Office Building • Harrisburg,PA 17120-0029 • (717)787-5280
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