HomeMy WebLinkAboutFiller, Jeffrey - 2021 2nd Friday Pre-Election Pennsylvania Department of State
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Bureau of Campaign Finance&Civic Engagement
'' 210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4)
www.dos.pa.govicampaigntinance • ra-stcampaigntinance@pa.gov
Unsworn Statement in Lieu of Sworn Statement for
Campaign Finance Reports
lace: reriict LULU-A.D, wrflth`C/Vd stytred m w raw'an' Aprii Lu, LULU ana arrows for unsworn
dellorations, Campaign Finance Reports(form-DSEB S02), 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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Repo 4 g - ktag
❑ Cycle 1 ❑ Cycle 2 ❑ Cycle 3 ❑ Cycle 4 1=c4 ycle 5
6` Tuesday 2nd Friday 30 Day 6th Tuesday 2'd Friday
j . rt t. Pre-Election
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❑ Cycle 6 ❑ Cycle 7 ❑ Cycle 8 ❑ Cycle 9
30 Day Post-Election
Annual Report 2nd Friday Pre-Special Election 30 Day Post-Special Election
Part►- 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.
1610101
Signature of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY)
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Printed Name Location (City/State/Country)
DSEB-502R
Updated 6/24/2020
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COMMONWEALTH OF PENNSYLVANIA
CAMPAIGN FINANCE STATEMENT
•
File this in lieu of a fuii report only if aggregate receipts, expenditures, or
liabilities incurred each did not.e.xceed $250_00 during the renortina nerinrL
FILER IDENTIFICATION Or REPORT FILED _ '. -
CANDIDATE VVV COMLTII.Ctt 1- - L088Y157 J.
NUMBER ON BEHALF OF ` -
NAORF,OF ,LING RSMCi'rEE,CAND�R LOB � vt./
ATRFFT ADD U/
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CITY 'STATE ZIP CODE
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TYPEOFREPORT 1 NAME.OF OFFICE SOUGHT BYCANDIDATE DISTRICT.NO. PARTY DATE OF ELECTION
(CHECK ONE) r MO.. DAY YEAR
o�ml �vcavnr II �4tr 1-4/1, r- VV U I
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PRE-PRIMARY f FOR OFFICE USE ONLY
MO. DAY YEAR MO. DAY YEAR - '(-".0 ._. - ...
DATES OF
ZND fRIDAY REPORTING TO C o
PRE-PRIMARY ' PERIOD - '�
30 DAY
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3' .... CZ)C'7
POST-PRIMARY I{ `` t,,,y ...,,4
6TH TUESDAY 4' OF REPORTING PERIOD: _____0.________ O
PRE-ELECTION Q '
TOTAL AMOUNT OF FILER'S
-Zia RiDAY
OUTSTANDING DEBTS OR LIABILITIES CD
CD
ooEx,_EC:loN AT THE END OF REPORTING PERIOD: $ C -13
in r.!- . . I I I I II w
JAt.TENt9NI4NT'
POST-ELECTION REPORT? YES NO
7.
ANNUAL TERMINATION YES, N0, 4.0
REPORT.. REPORT?
__._ ,_..__-.------------.AFFIDAVIT SECTION
1 IYY%'Y •
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 AGORE TATF RFC;FIPTS OR I71SRI IRSFMENT$OR LIABILITIES INr.I IRKED DURING THE REPORTING REalco INDICATED AECIVF CIA Nor
EXCEED TWO HUNDRED AND FIFTY DOLLARS($250.00)AND THIS REPORT IS,TO TIME BEST OF MY KNOWLEDGE AND BELIEF,TRUE,CORRECT AND COMPLETE.
V—D OF V 2011 IOFF PERSO SUBIVII INGREPPO`RTRTa
G' RE PRA ED NAME
MY C ?JIMISSIO IRESf`� c �� �(y�A �
MO. DA YR. AREA CODE AYTIME TEIEPHb E N IMSER
I - I
P'ARTII-
If statement is filed on behalf of a Candidate's Authorized Committee,Candidate must sign here.
's,WEArz(OR rr m)TI-AT TC THE BEST OF,.iv KNOWLEDGE AND liELIEF i I ES POLITICAL COMMITTEE EE 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
I I
Department of State • Bureau of Commissions,Elections and Legislation
DSEI3-503(12-99) 210 North Office Building • Harrisburg,PA 17120-0n2g e (717)7n7-52598-)