HomeMy WebLinkAboutPerry, Safronia - 2021 2nd Friday Pre-Primary 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.
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❑ 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 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.
Signature of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY)
Printed Name Location (City/State/Country)
DSEB-503
Updated 6/24/202
\izu7
s Pennsylvania Department of State
Bureau of Campaign Finance&Civic Engagement
ttlf 210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4)
-1, www dos pa.gov/campaignfinance • ra-stcampaignfinance@pa.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 foregoing is true and correct.
. c,Ifio-y„, R,II cM OqD7Prat
Signature of Candidate Date (DD/MM/YYYY)
crq.)0
i
0 a I 1.,S0 A R_S-A
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.
FILER IDENTIFICATION ' REPORT FILED , CANDIDATE I.../ COMMITTEE 2 LOBBYIST 3
NUMBER ON BEHALF OF
NAME OF FILING COMMITTEE,CAN IDAT(E^OR LOBBYIST
'`t i a ?f(hri tea
STREET ADDRESS `
/0 We. -{ qm-Pc-P-1-- : .
CITY n STATE ZIP CODE
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY 4 DATE,'.OF:ELECTION,';.7.-,''-
(CHECK ONE) .-��',�/� MO. DAY YEAR
I.
LJ L1
6TH TUESDAY r(1kcVA C ol„nl' i 1 �� o . i y_ aQQt
PRE-PRIMARY FOR OFFICE USE ONLY
MO. DAY YEAR MO. DAY ll
2ND FRIDAY 2. / DATES OF
PRE-PRIMARY ✓/ PER ODTING 05 o� I TO o MI
•30 DAY 3'
POST-PRIMARY. k
CASH BALANCE AT END /e
6TH TUEsonv 4. OF REPORTING PERIOD: $ c 1 ......
PRE-ELECTION t.:13
TOTAL AMOUNT OF FILER'S rT i 'y'
--c
5OR LIABILITIES 2ND FRIDAY OUTSTANDING DEBTS h '�"
. PRE-ELECTION AT THE END OF REPORTING PERIOD: $ ._.,_,_.Li
.mot...
30 DAY. 6.
POSTELECTION AMENDMENT YES NO C) M
REPORT? eD
7. lS?
ANNUAL 'TERMINATION
REPORT REPORT? YES NO Cl
.C.-
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($250.00)AND THIS REPORT IS,TO THE BEST OF MY KNOWLEDGE AND BELIEF,TRUE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED/ B\ BEFORE ME THIS ��}� n 1yy j 9u.AALL7 DAY OF t 1 . L 201 SIIGG146"{kUU�IRIE lOFF1LPERSO UBMITTIREPORT
ali1 ( mtQ 2 - C(ht�(bl(1 i G -��'n
< SIGNATURES PRINTED NAME
MY COMMISSION EXPIRES 3
MO. DAY YR. AREA CODE DAYTIME TELEPHONE NUMBER
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
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
DSEe-503(12-99) 210 North Office Building • Harrisburg,PA 17120-0029 • (717)787-5280