HomeMy WebLinkAboutLandis, DJ - 2021 30-Day Post-Primary TryPennsylvania 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-stcampaienfinance@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
LAA4k1.5
Reporting Cycle Name
❑ Cycle 1 ❑ Cycle 2 'Cycle 3 ❑ Cycle 4 ❑ 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
❑ Cycle 7 0 Cycle 8 ❑ Cycle 9
30 Day Post-Election
Annual Report 2"d Friday Pre-Special Election 30 Day Post-Special Election
Part l - 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, the lobbyist 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.
4111, .42616_'
04'
Signatur- of Treasurer, Candidate, or Lobbyist Date (D /MM/YYYY)
Printed Name Location (City/State/Country)
DSEB-502R
Updated 1/22/2021
In
Commonwealth of Pennsylvania-Campaign Finance Report
(Note:This report must be clear and legible.It should be typed)
Filer Identification Report Filed By Candidate (X Committee "Lobbyist '
Number (Mark X) IX
Name of Filing Committee,Candidate or
Lobbyist b te6g —$
Street Address 1 « b.( FY,A kit- '6WD
City auV n � State VA Zip Code liv-D
Type of Report(Place x under report type)
1-6`h Tuesday 2- 2nd Friday 3-30 Day Post 4-6th Tuesday 5-2"d Friday 6-30 Day Post 7-Annual Special 2"a Friday Special 30 Day
Pre-Primary Pre-Primary Primary Pre-Election Pre-Election Election Pre Election Post Election
IX
Date Of Election Year Amendment Termination
(MM/DD/YYYY) 6 ((1 ).ol( Report Report
Summary of Receipts and From Date To DateI For Office Use Only
Expenditures
A.Amount Brought Forward From Last Report $ )i
B.Total Monetary Contributions and Receipts $
(From Schedule I) b•
C.Total Funds Available $ COc�
(Sum of Lines A and B) �{f7t i O r r =
D.Total Expenditures $ pp -
(From Schedule Ill) 15k.--v --
E.Ending Cash Balance $ C w.
(Subtract Line D from Line C) — �� b
F.Value of In-Kind Contributions Received $ _ 0
(From Schedule II) ' U 'fri) Z: -
G.Unpaid Debts and Obligations $ --‹ ry
(From Schedule IV) 12•VV
Affidavit Section
Part 1-If this is a Committee report,treasurer sign here.If this is a Candidate report,candidate sign here.
I swear(or affirm)that this report,including the attached schedules on paper,' k best of my knowledge and belief true,correct and complete.
Sworn to and subscribed before me this NoVH Sc
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E�-, ��aH 2 i n u of'P��so ttin report
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Sign G�0 Q,0\• aR`be e p\cee '0- Printed Name
My Eione !>
GP tam\ss•se kv10 t 1/1 /lA✓ �1g&3
MO. DAY .Go06\s Area Code Daytime Telephone Number
Part II-If this is a report of a Candidate's Autho ized Committee,candidate shall 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
day of 20 '
signature of Candidate
•
Signature I Printed Name
My Commission expires
MO. DAY YR. Area Code Daytime Telephone Number
SCHEDULE HI .
Statement of Expenditures
Twltlentificatiari Number•
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