HomeMy WebLinkAboutEvans, Mercedes - 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-stcampaignfinanceppa.gov
Unsworn Declaration in Lieu of Sworn Statement for
Campaign Finance Statements
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 Statements. This form must be
signed by hand where a signature is required.
Name of Filing Committee,Candidate, or Lobbyist
Mercedes Evans
Reporting'Cycle Name
0 Cycle 1 ❑ Cycle 2 0 Cycle 3 0 Cycle 4 IM 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 0 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 statement in lieu of full report by a political
committee, the treasurer must sign here. if this form is submitted with a statement in lieu
of a full report by a candidate, the candidate must sign here. If this form is submitted with
a statement in lieu of full 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 Statement is true and correct.
6414, 10/20/2021
Signature of Treasurer, Candidate, or Lobbyist Date(DD/MM/YYYY)
Mercedes Evans Camp Hill, PA 17011
Printed Name Location (City/State/Country)
DSEB-503S
Updated 1/22/2020
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.
FILER IDENTIFICATION REPORT FILED CANDIDATE Iic COMMITTEE 2 LOBBYIST J
NUMBER ` ON BEHALF OF ,
NAME OF Ell
l ir(e -`fr/1 kTE OR LQBBYISTcL 3
STREET ADDRESS ^j��s/�"
()OC)i KOver it1 Rd.
CITY j'^� VP p Hill, STATE r ri ZIP 01 _29z 5-"
TYPE OF*P REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) j / „m Hjii
�r® alioD MO. DA7Y- YEA�
6TH'TUESDAY • 1/�YL/f/f11/ Il _ OG" [/f 1
PRE-PRIMARY FOR OFFICE USE ONLY
MO. DAY YEAR111 MO. DAY I YEAR
. DATES OF
2ND FRIDAY 2 REPORTING bV f� �I To f1 )/ f l'
PRE-PRIMARY PERIOD �l a li// i! C,
30 DAY 3' rLa
POST-PRIMARY tij
CASH BALANCE AT END0 F i t CD
4. OF REPORTING PERIOD: $ `1,,:I -..�
6TH TUESDAY ^-- •
PRE-ELECTION
TOTAL AMOUNT OF FILER'S - N
5. OUTSTANDING DEBTS OR LIABILITIES0
2ND FRIDAY AT THE END OF REPORTING PERIOD: $ "'
PRE-ELECTION ` L
6.
30 DAY cii
AMENDMENT ��//
POST-ELECTION REPORT? YES NO x ;m
ANNUAL TERMINATION YES NO 7�
REPORT REPORT? /// ��`
AFFIDAVIT SECTION
PARTI-
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 K OWLEDGE AND BELIEF.TRUE,CORRECT COORRRECT/AANDD COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS ,�./_�� _ /� �f krial�
DAY OF 2Q_ MercezVts &N. SUBMITTING PORT
,\MVjrE(/`/"AI✓L,,'^,
PRINTED NA
SIGNATURE
MY COMMISSION EXPIRES 1 �r &— /f ,G..�
MO. DAY YR. AREA CODE DAYTIME TELEPHONE NUMBER
PART II- '
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 BEUEF 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