HomeMy WebLinkAboutGossert, Michael - 2021 30-Day Post Election 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 1• OMMITTEE Z LOBBYIST- 3.
NUMBER ' ON BEHALF OF '
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST
tJ\% t..-\•„ 0..-e. 6oS. -1 -
STREET ADDRESS
Cpgo C1�e tZ\‘...e d- S 4A-JC-- C-
CITY STATE ZIP CODE
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) \\ MO.
DAY YEAR
t' W IrQ �r /V /Pf lOn / V /� g .0 // L Z-6TH TUESDAY •
PRE-PRIMARY FOR OFFICE USE ONLY
'MO. DAY YEAR MO. DAY YEAR •
2• DATES OF
'2NDiFRIDAY REPORTING TO
PRE4RIMARY PERIOD
•30 DAY .. 3'
POST-PRIMARY
CASH BALANCE AT END C: r,.,
.6TH TtlEsoaY 4' OF REPORTING PERIOD: $ le
PRE-ELECTION • 1
TOTAL AMOUNT OF FILER'S rti
5 OUTSTANDING DEBTS OR LIABILITIES
2ND,FRIOAY r'-' I
PRE-ELECTION -
AT THE END OF REPORTING PERIOD: $ M I�fl
1
B
30 DAY -mil
POST-ELECTION AMENDMENT YES NO CD l!
REPORT? CD
7, = .•
,ANNUAL . TERMINATION ... •
REPORT REPORT? YES NO --1
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 UABILITIES 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 ND COMPLETE.
SWORN TO AND SUB CRIBED BEFORE ME THIS /
Z DAY OF i L. i� 20 I NATURE OF PER ON UBMrrTING REPORT
2.4.4.54-70-‘jc_o___
PRINTED NAME
SIGNATURE ^�
MY COMMISSION EXPIRES S I i( Ao �L /✓/
/ 7 36 3 c G S--
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. •
R(OR AFFIRM)T e :Ili. + I :ND - EF THIS POLITICAL COMMITTEE HAS NOT VIOLATED ANY PROVISIONS OF THE ACT OF
JUN . 1937(P.L. 131o. .+_ A {�S LYtva Nola Seal
a orce, ry Publicry
SWORN FO AND S I•- C•�IE1fiD.eg Is '' •'' County
AY OF ? expiresAug O24 SIGNATURE OF CANDIDATE
,, i ,, ..• on number ust .
S l aria Association of Notaries
t? ►�/ '—:7V PRINTED NAME
SIGNATURE
MY C ISSION 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