HomeMy WebLinkAboutCommittee to Elect Safronia Perry - 2021 6th Tuesday Pre-Election I.
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 Statement 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 unworn
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 Reports. This form must be signed by hand where a signature is required.
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0 Cycle 1 0 Cycle 2 0 Cycle 3 aCicl 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
0 Cycle 7 ❑ Cycle 8 0 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, the lobbyist must sign here.
I declare under penalty of perjury under the law of the Commonwealth of Pennsylvania
thatthe- going is true and correct.
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Signature of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY)
(Pri‘Ce(q) /4"
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Printed Name Location (Ci /State/Country)
DSEB-502R
Updated 6/24/2020
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Commonwealth of Pennsylvania-Campaign Finance Report
(Note:This report must be clear and legible.It should be typed)
Filer Identification Report Filed By Candidate Committee i fv Lobbyist
Number (Marts X) 1
Name of Filing Committee,Candidate or J� / / 5.4
Lobbyist rh lM in I fe 'f D t /e L T- - 6){. /-e r/7
Street Address 0
I A fCSL 7��d /'_ �Lrre 1- I- 1
City �'Gr-t Co vV State7 f, i y lap Code ) 7 )13
Type of Report(Place x under report type) 1
1-6th Tuesday 2- 2nd Friday 3-30 Day Post 4-6tTuesday 5-2"d Friday 6-30 Day Post 7-Annual Special 2rt0 Friday Special 30 Day
Pre-Primary Pre-Primary Primary Pre-Election Pre-Election Election Pre-Election Post-Election
X
Date Of Election Year Amendment Termination
(MM/DD/YYYY) Report Report ri
Summary of Receipts and From Date To Date For Office Use Only
Expenditures 6 jef/2/ Dl3��A.Amount Brou ht Forward From Last ort t I
g P I95". . 52.
B.Total Monetary Contributions and Receipts S
(From Schedule I)
C.Total Funds Available 8
(Sum of Lines A and B) ) 7 Ste$ 52 n
D.Total Expenditures S = 1-4
(From Schedule III) t
o
E.Ending Cash Balance 8 r0
r�1 or)
=
(Subtract Line D from line C) �j Z I "0
F.Value of In-Kind Contributions Received E �, > r`?
(From Schedule II)
G.Unpaid Debts and Obligations 8 - - }
(From Schedule IV)
t`.. N
Affidavit Section CJ't
Part 1-If this is a Committee report,treasurer sign here.If this is a Candidate report,candid re. —I r'
I swear(or affirm)that this report,Including the attached schedules on paper,is to the st of ge_d an ief true,co et:tand complete.
Sworn to and subscribed before me thi /2e
day of 20 • I G6
i_________,
eu
Signature of Palo;S0pr 4,-Ztting re-
et tiL
Signature w/� Printed Name �
My Commission expires 7 4 7/-6 ( 7'0
MO. DAY YR. Area Code Daytime Telephone Number
Part II-If this is a report of a Candidate's Authorized '1 ittee,candidate shall sign here.
I swear(or affirm)that to the best of my knowled..an : this political committee has not violated any pr'visions of the Act of June 3,1937(P.L.1333,NO.320)as
amended. *Sias
Sworn to and subscribed before me this �,,�klIz::4.4., —1/ Id; I I
1 I y. —' _
S+day of 0 �,' ~
'�rg4.�4„),'i, s Signature o Candidate
�/�� ` 41j I- (a. 44/ (i( (g .t Pr nted Name
My Commission expires . 14 ova� -7 n TSM0. 1 01.Sa
M0. DAY YR. Area Code Daytime Tetephone Number
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