HomeMy WebLinkAboutChippo, Sherri - 2021 30-Day Post Election 4 1 Pennsylvania Department of State
', Bureau of Campaign Finance&Civic Engagement
.:. 210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4)
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..� www.dos.pa.gov/campaignfinance • ra-stcampaignfinance@pa.gov
Unsworn Statement in Lieu of Sworn Statement for
Campaign Finance Statements
Note: Per Act 2020-15, which was signed into law on April 20, 2020 and ailowsr unworn
declarations, Campaign Finance Reports (form DSEB-502), Campaign FinanceStat rents In lieu
of full reports (form DSEB-503), and Independent Expenditure.Reports(form DSB-5?5)need not
be notarized. Instead, the filer may file with each report or statement the cortespdriJling version
of this form signed by the required individual(s). This particular form is to fie t' ed only for
Campaign Finance Statements. Thisform must be signed byhand where a si`natu�-is required.
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I abiEDAJJORO Committee, Candidate,C•Btobb ,
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Reporting ('
❑ Cycle 1 Cl Cycle 2 *Cycle 3 ❑ Cycle 4 0 Cycle 5
6th Tuesday 2"d 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 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 foregoing is true and correct.
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Signature of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY
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Printed Name Location (City/State/Couunnfry)
DSEB-503S
Updated 6/24/2020
a
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.
FILERU IDENTIFICATION ' ON ORT BEHALF , :-CANDIDATE I�`COMMITTEE;. 2. LOBBYIST' 3.
NUMBER ON BEHALF OF
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST
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r'niv\eci,,o, X STATE LP CODE
TYPE OF REPORT NAME OF OFFICE ``l ^Y CANDIDATE �; DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) �i` _L t LCi ,
ti ,
GTHTUESDAY'...;
PRE-PRIMARY.' FOR OFFICE USE ONLY
MO.. :. ,.DAY: YEAR :.MO. ..-.DAY ' :':YEAR, . .
2ND FRIDAY 2' DATES OF
PRE-PRIMARY PERIOD NG \O \ 1 do \ TO \\ (93..
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30:DAY . .
3.
POST-PRIMARY
CASH BALANCE AT END //rr��
6TH TUESDAY.;'"'';::'
4.
OF REPORTING PERIOD: $ lJ`
PREELECTION . . -:, r.,,a
TOTAL AMOUNT OF FILER'S
OUTSTANDING DEBTS OR LIABIUTIES r�
ZND FRIDAYPRE=ELECTION AT THE END OF REPORTING PERIOD: $ a 0 v
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6. -- 1
30 DAY AMENDMENT
POSTELECTION X REPORrr YES N0
7. C I l J ANNUAL TERMINATION; YES �
REPORT
REPORT t: ..... r-W
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(6250.00)AND THIS REPORT IS,TO THE BEST OF MY WLEDGE AND BELIEF,T CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS SI3`
DAY OF 20 --SIG`NATUURE OF PERSON SUBM REPORT
:\vim
SIGNATURE PRINTED NAME\
MY COMMISSION EXPIRES \7 l' L( E R I
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 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.
DSEB-503(12-99)