HomeMy WebLinkAboutLandis, DJ - 2021 2nd Friday Pre-Election fiPennsylvania 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 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
Low s
Reporting Cycle Name
❑ Cycle 1 ❑ Cycle 2 ❑ Cycle 3 ❑ Cycle 4 I Cycle 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 2nd 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 accompanying Campaign Finance Report is true and correct.
IS . 6(A.-,2. /6///
Signature of Treasurer, Candidate, or Lobbyist Date DD/MM/YYYY)
Printed Name Location (City/State/Country)
DSEB-502it
Updated 1/22/2021
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 110, REPORT FILED 2 3
CANDIDATE X COMMITTEE LOBBYIST
NUMBER ON BEHALF OF OP
_
NAME OF F )I G ITTEE,CANDIDATE OR LOBBYIST
C Z
I, /a fa/--5
STREET ADDRESS
1/7 Waihnvd CITY STATE STATE ZIP CODE
etc d1iner/a92d _1/9 /9076 *—
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) MO, DAY YEAR
Brit TUESDAY
1 44 CO(1,..i/ aNk4e)/ /0 a .2/
PRE-PRIMAIRY FOR OFFICE USE ONLY
MO. DAY YEAR MO. DAY YEAR ,
.2 DATES OF
2ND FRIDAY -
PRE-PRIMARY ZP2(I)ORDTING At 0 t 21 r° t° (
30 DAY 3.
POST-PRIMARY
CASH BALANCE AT END 6TH .
TUESDAY . I OF REPORTING PERIOD: $ C.": *-^"
c="
PRE-m.6010N
TOTAL AMOUNT OF FILER'S
5. OUTSTANDING DEBTS OR LIABILITIES 0 ' (lb rel c:,
2ND FRIDAY
:7* c-3
X
PRE-ELECTION AT THE END OF REPORTING PERIOD: $ — r--
-.... No
.....„ N..)6.
30 DAY
AMENDMENT C.::1
POSTELECTION YES NO
(-II 13
REPORT?
—7. I CD LA.)
ANNUAL " • TERMINATION yEsC..-: .•
REPORT REPORT? NO '
-4, ,0
AFFIDAVIT SECTION
PART I-
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 KNOWLEDGE AND BELIEF,TRUE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS A A
DAY OF 20 f NATURE 5 PERSON SUBMITTING REPORT
CD(r 2a/)d-i-5.
PRINTED NAME
SIGNATURE
MY COMMISSION EXPIRES //?/27V-6 g6 3
MO. DAY YR. AREA CODE DA, IME 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 BELIEF Ti-OS 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
0SE13-503(12-99) 210 North Office Building • Harrisburg,PA 17120-0029 • (717)787-5280
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