HomeMy WebLinkAboutCoplen, Rick - 2021 2nd Friday Pre-Election 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 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 Reports. This form must be signed by hand where a signature is required.
pitk Copley)
❑ Cycle 1 ❑ Cycle 2 ❑ Cycle 3 ❑ Cycle 4 MCycle 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 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
that the foregoing is true and correct.
/U z/ Z° 2I
Signatur er, Candidate, or Lobbyist Date ( D/M /YYYY)
/ C/.
//0 V-0
Prin er
Name Location (City/ tate/ ountry)
DSEB-502R
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.
NUMBER
FILER ENTIFlCA7ION , f2 0�,0 0 J 6 5 R REPORTBEH FILED
OF 0. CANDIDATE 15, COMMITTEE 2. 1.OB8YIST 3.
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST J/
?let< Gojaz iv
STREET ADDRESS n
`60 6 f}Icy woEg 5 PaZli�G' ( -04-cX—
CITY STATE ^�� /21.45Z-6- � LP CODE 1.5 —
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) •(I/ 1j -/n/ f lids 0 C J1 DS//— MO. /DRAY YEE�A/RJ
6TH TUESDAY
1. 5CkoDI. 6e,,,,, D6fie-rO� (/,J F(Le - /1 f h 1
PRE-PRIMARY L FOR OFFICE USE ONLY
M.O. I DAY YEAR MO. DAY YEAR - -
2ND FRIDAY z' DATES OF
PRE-PRIMARY PERIOD NG / e5 ,' TO10 ic6 Ai ,("",i >
30 DAY 3' - - - - CO —
POST-PRIMARY �� )
CASH BALANCE AT END -
67H TUESDAY °' OF REPORTING PERIOD: $ �, N
PRE-ELECTION ..may,
TOTAL AMOUNT OF FILER'S t
2ND FRIDAY $ OUTSTANDING DEBTS OR LIABILITIES
PRE-ELECTION f\ AT THE END OF REPORTING PERIOD: $ r.�
8. ..
30 DAY - - AMENDMENT .s-•:: w
POST-ELECTION REPORT? YES NO K -I
T s
ANNUAL TERMINATION
• REPORT REPORT? YES NO '
AFFIDAVIT SECTION
PART I-
1f 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 . sVLEDGE AND IEF,TRUE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS
DAY OF 20 SIGNA SON SUBMIT” REPORT
/C/C CA
SIGNATURE PRINTED NAME MY COMMISSION EXPIRES 7/� 2 6- / -- l- //�L/f
S
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
DSEB-503(12-99) 210 North Office Building • Harrisburg,PA 17120-0029 • (717)787-5280
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