HomeMy WebLinkAboutLandis, DJ - 2021 30-Day Post Election ItrifPennsylvania 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.gay
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
Reporting Cycle Name
❑ Cycle 1 ❑ Cycle 2 ❑ Cycle 3 ❑ Cycle 4 ❑ 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.
l
9/
Signat 4 of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY)
.J . lau, i S k(tuAryt6,44aa W
Printed Name Location (City/State/Country)
DSEB-502R
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 ' REPORT FILED CANDIDATE' X COMMITTEE. LOBBYIST
NUMBER - _____ON BEHALF OF (( �\
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST
I __
STREET ADDRESS
STATE ZIP CODE
CITY 14 cv c Ei.L 1) PA 1 ,- , .„.......
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) W2at t� R- MO. - DAY YEAR
STH TUESDAY
OP N.ta 6Ru>a 1) u v2 /?)`t)2(
. PRE-PRIMARY FOR OFFICE USE ONLY,
MO. DAY YEAR .. MO. DAY YEAR I- _-
2ND FRIDAY. 2. DATES OF
REPORTING i 0 C el n l TO 11 �� 24
PRE-PRIMARY I PERIOD V t fi
30 DAY
a.
POST-PRIMARY
CASH BALANCE AT END A 61)
t TH TUESPAY a. OF REPORTING PERIOD: $ •; ti
PRE-ELECTION
TOTAL AMOUNT OF FILER'S ,m -1,
5. OUTSTANDING DEBTS OR LIABILITIES , V V
P2RE FL PRE-ELECTION AT THE END OF REPORTING PERIOD: $ 1-.1 T'`'t
PRE=ELECTION C-,
B. 'f 1
--,
30 DAY AMAMENDMENTPOST 1 `ELECTION. REPORT? YES NO
ANNUAL TERMINATION YES NO X 5,,+,D
REPORT - REPORT? / `
L'
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(S250.00)AND THIS REPORT IS,TO THE BEST OF MY KNOWLEDGE AND BELIEF,TRUE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS
20 IG A r 2E OF PERSON SUBMITTING REPORT
DAY OF _ 1 j kg 0 15
PRINTED NAME
SIGNATURE -1 ll ii� (%(_
MY COMMISSION EXPIRES `b L.
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 a0_
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