HomeMy WebLinkAboutEvans, Mercedes - 2021 30-Day Post Election irs Pennsylvania Department of State , .
Bureau of Campaign Finance&Civic Engagement
210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4)
www.dos.oa.Qov/camoaianfinance • ra-stcampaianflnancehaa.aov
Unsworn Declaration in Lieu of Sworn Statement for
Campaign Finance Statements .- ,
Notes Per Act 2020-15f which war signed=into law on.April 20,'.2020 and.allows for'unworn
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 pareliular,foie 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
}
Mercedes Evans '
Reporting Cycle Name
0 Cyde 1 0 Cycle 2 0 Cycle 3 0 Cycle 4 0 Cycle 5
6th Tuesday 2nd Friday 30 Day 6"'Tuesday 2"d Friday
Pre-Primary Pre-Primary Post Primary Pre-Election Pre-Election
' i(Cycle 6 0 Cycle 7 0 Cycle 8 Cycle 9
30 Day Post-Election Annual Report 2"d Friday Pre-Spedal 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.
ouitdo....
11/30/2021
Signature of Treasurer, Candidate,or Lobbyist Date(DD/MM/YYYY)
Mercedes Evans Camp Hill, PA, 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
ON BEHALF OF CANDIDATE, REPORT FILED COMMITTEE 1. LOBBYIST 1
NUMBER
NAME OF FILIN CO MITTEE CANDIDA OR LOBBYI-1 --
I '
V roc 6 s bwerva nS
STREET ADDRE6 '-
I
d .
CITY � 'STATE ZIP CO
rl ° 1. I I , b i -- f?2c
TYPE OF REPORT 'N/gIIjE OF OFFICE SOI'GHT BY CANDIDATE jDISTRICl NO. PARTYD DATE OF ELECTION
(CHECK ONE) / '/�rI✓ li ` �J�J'{�/,jq/J�l i y )STH'TUESDAY �. Lt/Li)I V( M0. DAY all-
)YEAR
PRE-PRIMARY FOR OFFICE USE ONLY
• MO. DAY YEAR MO. DAY YEAR
2ND FRIDAY 2. DATES OF ff�'� I
jPRE-PRIMARY REPORTIPERILNG 6V1.7 1.1 TO 9.9" �I 30 DAY3' !j ) .,T POST-PRIMARY -W,...
CASH BALANCE AT END
4. OF REPORTING PERIOD: $ 1 I •
6TH TUESDAY t
PRE-ELECTION w I r'�'9
TOTAL AMOUNT OF FILER'S r-.-
2ND FRIDAY 5. OUTSTANDING DEBTS OR LIABILITIES i
PRE-ELECTION
AT THE END OF REPORTING PERIOD: $ N
.10
30 DAY 7
AMENDMENT
POST-ELECTION REPORT? YES 1 NO . :.' L O
7. IK. C.::::
REPORT ANNUAL
TERMINATION YES NO X
REPORT? /
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 h KNOWLEDGE)A/N/DD/B/ELIIIEEEEFTRUE,CO T AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS �`��/`N 6 ✓�� C�^' (/ � .
DAY OF 24_ a 'SIGNATURE RS N UBMITTI JEPORT
N trea �� Va
• PRINTS NAME •
SIGNATURE 111 (,fl '3'/JJJ/I 3
MY COMMISSION EXPIRES
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 BELEF THIS POLITICAL COMMIYTEE 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
DSEB-503(12-99) 210 North Office Building • Harrisburg,PA 17120.0029 • (717)787-5280