HomeMy WebLinkAboutFriends of Dale Sabadish - 2021 2nd Friday Pre-Election ffifPennsylvania 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 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
Rticabs OF 1)itt6 cAMDIS
Reporting Cycle Name
❑ Cycle 1 ❑ Cycle 2 ❑ Cycle 3 ❑ Cycle 4 g Cycle 5
6th Tuesday 2nd Friday 30 Day 6th Tuesday 2"d 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 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.
datvt:gesv.jeoe(
14/1.I1707 I
Signature of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY)
a100.48icc 6.4 i tiK ce / US
Printed Name Location (City/State/Country)
DSEB-503S
Updated 1/22/2020
cifPennsylvania 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
Part II - If this is submitted with a statement in lieu of full report by a Candidate's
Authorized Committee, candidate sign here.
I declare under penalty of perjury under the law of the Commonwealth of Pennsylvania
that the accompan inglCampaign Finance Statement is true and correct.
/0-AA-ar
Signature of ndidate Date (DD/MM/YYYY)
YRGc .CASATAIS H I4SCIMailaka.I PR I USA
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
NUMBER OF CANDIDATE I COMMITTEE i)4 LOBBYIST 3.
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST
FQ Iw c of �ieet9cs ii
STREET ADDRESS
S. vitgC"/ (ham'
CITY STATE ZIP CODE
/IAe414 $41-4),M4 PA I?off'
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) oeaal1• MO. DAY YEAR
/
. /_rAGo iwN(PA
67H TUESDAY
PRE-PRIMARY FOR OFFICE USE ONLY
MO. DAY YEAR MO. DAY YEAR
2.
2N0 FRIDAY
DATES OF
PRE-PRIMARY PER O v DTING 6 a 202 I TO 10 (8 '
30 DAY 3'
POST-PRIMARY CASH BALANCE AT END a
6THTUEsnA4: 4. OF REPORTING PERIOD: $ 015 —'
PRE-ELECTION rri
TOTAL AMOUNT OF FILER'S
5. OUTSTANDING DEBTS OR LIABILITIES r""2ND --r
PRE FRIDAELECTI X AT THE END OF REPORTING PERIOD: $ 'Z/ .� N.)
PRE=ECECT10N
-v
B. L:}
30 DAY. AMENDMENT C7
POST-ELECTION REPORT? YES NO
7. ••..
ANNUAL TERMINATION ^--
REPORT REPORT? YES NO X. -'1 N.)
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 UABIUTIES 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 / .
DAY OF 20 SIG ;E i •SON SUBMITTING REPORT
SO% 6404#461/(4.1
SIGNATURE PRINTED NAME
MY COMMISSION EXPIRES -7I `6 W
MO. DAY YR. AREA CODE `J 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 BEUEF THIS POUT' M E HAS N T VIO D ANY PROVISIONS OF THE ACT OF
JUNE 3, 1937(P.L.1333,No.320)AS AMENDED.
SWORN TO AND SUBSCRIBED BEFORE ME THIS
SIG ATU OF CANDIDATE
DAY OF 20 1
///INTED NAME
SIGNATURE 4/
/
/J- 3 3_�l 276
MY COMMISSION EXPIRES - DAYTIME TELEPHONEEL 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