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HomeMy WebLinkAboutFriends of David Fish - 2021 30-Day Post-Primary 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-stcampaignfinanceppa.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 PW_-b/l'Ps or 0,4v1.72 Reporting Cycle Name ❑ Cycle 1 ❑ Cycle 2 A 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 ❑ Cycle 7 ❑ Cycle 8 0 Cycle 9 30 Day Post-Election Annual Report 2nd Friday Pre-Special Election 30 Day Post-Special Election Part 1 — 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. 4!,W/O6/�ZDoi. Signature o Treasurer Candi ate or Lobbyist Date (DD/MM/YYYY) t92,at, , 1srl VO ' f ultbn Ern p/Pt/>is Printed Name Location (City/State/Country) DSEB-503S Updated 1/22/2020 IPennsylvania Department of State Bureau of Campaign Finance&Civic Engagement 210 North Office Building,Harrisburg,PA 17120 •• 717.787.5280(Option 4) �:, www.dosjm.eov/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 accompanying Campaign Finance Statement is true and correct. Diti,jt9-%--/ C� - 1 )- _ 1 Signa of Candidate Date (DD/MM/YYYY) Gwt s - t Sk 144.A ( /V T ') -P jar f 154d Printed Name Location (City/State/Country) DSEB-5035 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 IDENTIFICATIONlio• REPORT FILED CANDIDATE I. COMMITTEE 3 / LOBBYIST 3 NUMBER ON BEHALF OF �/ NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST FR.-2,- 4'P5 Or P. 1'i ' f.Z3/I STREET ADDRESS 25 L4MP pd67" LAL CITY STATE ZIP CODE 6Ane la PA- r Tait — Iiaf TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION (CHECK ONE) '�V J� II I MO. DAY YEAR 1 /4)1m rd j 11 4m/niybivl�P Ot;rnOtt' 6TH TUESDAY - - �� � PRE-PRIMARY FOR OFFICE USE ONLY N.O. DAY YEAR N.O. DAY I YEAR -' 2ND FRIDAY 2. DATES OF PRE-PRIMARY PEERRIOD NG ©br. ,r AP TOD f(7 O �� I -y FlC 30 DAY 3, n " POST-PRIMARY Y/J t C_,.,. CASH BALANCE AT END �y (� IllC. 6TH TUESDAY 4. OF REPORTING PERIOD: $ I D3.o r =' PRE-ELECTION D,, ...�. TOTAL AMOUNT OF FILER'S s. OUTSTANDING DEBTS OR LIABILITIES C) 2ND FRIDAY PRE-ELECTION AT THE END OF REPORTING PERIOD: O'QQ 30 DAY 6. AMENDME ` G? POST-ELECTION REPORT NT YES NO 7. "'{{{/// ANNUAL TERMINATIONREPORT REPORT? YES NO 7 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(S250.00)AND THIS REPORT IS,TO THE BEST OF MY KNOWLEDGE AND BELIEF,TRUE,CORRECT AND COMPLETE. SWORN TO AND SUBSCRIBED BEFORE ME THIS e,/"" V,����y-��jY}fT1ING DAY OF 20SIGNATURE OF PERSON SUB . REPORT ,- /fy /r- 6/Ire,ry/. SIGNATURE PRINTED NAME MY COMMISSION EXPIRES 7/7 5.7q 6317 MO. DAY YR. AREA CODE DAYTIME TELEPHONE NUMBER PART 11- 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 MMITTEE HAS NOT VIOLA DANYYPP VISIONS OF THE ACT OF JUNE 3,1937(P.L.1333,No.320)AS AMENDED. _ —L / (.1 SWORN TO AND SUBSCRIBED BEFORE ME THIS rtJ`�'�// S ATURE OF CANDIDATE DAY OF 20_ C'"1 A-V' ,n 5- ' S�/ $ ii �11 +r/ PRINTED NAME/ �/ SIGNATURE �"") (� '7'\ - 6 6 C MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NUMBER MO. DAY YR. Department of State • Bureau of Commissions,Elections and Legislation DS1F.13-503(12-99) 210 North Office Building • Harrisburg,PA 17120-0029 • (717)787-5280 .. _ . ..... _________ —__--..._ ..._ - ...... .