HomeMy WebLinkAboutCoplen, Rick - 2021 30-Day Post-Primary Pennsylvania Department of State
IT 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 Reports
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 Reports. This form must be signed
by hand where a signature is required.
Name of Filing Committee, Candidate, or Lobbyist
<C i c tc_ Cop 1
Reporting Cycle Name
❑ Cycle 1 El Cycle 2 fi Cycle 3 ❑ Cycle 4 El Cycle 5
6th Tuesday 2"d Friday 30 Day 6th Tuesday 2"d Friday
Pre-Primary Pre-Primary Post Primary Pre-Election Pre Election
❑ Cycle 6 El Cycle 7 ❑ Cycle 8 ❑ Cycle 9
30 Day Post-Election
Annual Report 2"d Friday Pre-Special Election 30 Day Post-Special Election
Part I- If this form is submitted with a Committee report, the treasurer must sign here. If
this form is submitted with a Candidate report, the candidate must sign here. If this report
is submitted with a report by a contributing lobbyist, thelobbyist must sign here.
I declare under penalty of perjury under the law of the Commonwealth of Pennsylvania
that the accompanying Campaign Finance Report is true and correct.
/ D� 2a2/
Signa andidate, or Lobbyist Date ( /M /YYYY)
C ai9Z4 d'iifn/e,
Prin d Name Location ( Ity/Stountr
DSEB-502R
Updated 1/22/2021
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 2 O.2.
/0 O /a 5 ORN dEWLLF OPRr FILED ' CANDIDATE . 'X COMMITTEE. Z 'LOBBYIST 7.NUMBER
NAME OI,`OW�pIT CTEE,C,ANOfpATE OR OB�ST YV
STREET.ADDRESS
?OC /Q/ CaAver- S-r-/n? 4 a
City STATE ZIP CODE .. ........ . ..
t )Sel fil5 ie
TYPE OK REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY�9 DATE OF ELECTION
(CHECK ONE) ` Areff4r.
�.�,D `-�° MO. DAYY1:AR1. a-J [-�VV/ &QV/ 't/!//.� Q Z./
6TH TUESDAY. Z
PRE-PRIMARY- FOR OFFICE USE ONLY
MO: DAY YEAR MO. DAY YEAR _
2ND FRtOAY_ 2. DATES OF
PRE-PRIMARY... REPPOR 6 5-NG 0 2/ TO Q6 07 2_
30 DAY 3 C
POST-PRIMARY �.- ,.a
CASH BALANCE AT END :.a.
a. OF REPORTING PERIOD: $--4__. t_._ —
riRE-ELECTION
TOTAL AMOUNT OF FILER'S r"" ....-
2ND-FRIDAY OUTSTANDING DEBTS OR LIABILITIES -^-1
PRE-ELECTION;'
AT THE END OF REPORTING PERIOD: $
30 DAY, ...+
CD
POST-Et ECTION :: AMENDMENT YES NO Ce?
REPORT?
ANNUAL TERMINATION YES NO J� CD
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 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 ODE AND BELT F RUE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS
DAY OF 20_ 'SIGNATUR SON S BMITTIN�j REPOT
SIGNATURE RItdTED NAME
MY COMMISSION EXPIRES __ 44472 253/— ‘9zier
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 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
DSEB-503(12-99) 210 North Office Building • Harrisburg,PA 17120.0029 • (717)787-5280