HomeMy WebLinkAboutFish, David - 2021 30-Day Post Election 1112 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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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 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 individuol(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
OLV
Reporting Cycle Name
0 Cycle I. ❑ Cycle 2 ❑ Cycle 3 ❑ Cycle 4 0 Cycle S
6th Tuesday 2"d Friday 30 Day 6`h Tuesday 2"d Friday
Pre-Election
Pre-Primary Pre-Primary Post Primary Pre-Election
Cycle 6 0 Cycle 7 Cl Cycle 8 ❑ Cycle 9
30 Day Post-Election
Annual Report 2"4 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.
t fi1/4 07)e?-/
Signature of Treasurer,Candidate,or Lobbyist Date(DD/MM/YYYY)
Printed Name Location (City/State/Country)
OSE8.502R
Updated 1/22/207.1
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.
+TLar soornnCAT10N WHAT HLPI) CANO ATt J X {COMMIT/ft x , r.0 4Y3ST 3
AAMISPA '' ON BEHALF Of \\\ 11
NAME OF FILING COMMITTEE.CA YE OR LOCCY$1
1)e.Vi tol Ui ' Ft 5 iii
y
SIAM ADDRESS
SOS L ti Atr Pv i f L n/
CITY VPOOf
G 0 if t 11 STATE PA IC
if V t'dr
TYPE OF REPORT NAMIE OF OFFICE SOUGHT SY CANDIDATE DISTRICT NO. PARTY DATE OF ELECTION
(CHECK ONE) ,/ p r MO. DAY YEAR
0 Wn S t" (.d,1^NI i 5 t u 1v F/�
6TN TUESDAY �. '� --
PRE-PRfMARY FOR OFFICE 4-Of ONLY
-_ No. OAT YtIrt MO. DAY I YEAR - - - -
TES Or
PREPRI IAITY 2.ND FRIDAY � I° i i ?,t ID
/1 � a.
30 DAY '
PONT-PRIMARY
CASH BALANCE AT END },y
STx TUESDAY 4. i OF REPORTING PERIOD: $ r" v
«M r
PREELECTION
TOTAL AMOUNT OF FILER'Sa
2NO Fx10AY S OUTSTANDING DEBTS OR UAI31LfTil:S az
PRE-ELECTION AT THE ENO OF REPORTING PERIOD $ I— •4'4
// .> W
30 DAY V ___. .. .va.; CD
POST-ELECTION REPORT? YES : NO !X C..,,1 in
l l.;
ANNUAL TERM TAYWN YCS ND CD "
REPORT a sibarr? s,;,,r ..
A -
-
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(On AFFIRM)THAT Tut ACGrZGATE RECr"PTS OR C SSURSCI.E JTS DR U BU1RS PICLIRPCD OURT.G THE REPORTING PER'OJ TNDECATCD ADOVE DID Nor
MUD Two HUNDRED AND FIFTY warm($250,00)Arta TITS REPORT Is.TO PIS essT OF I,.KNOmEDGt :IO ISCI. '�,(Q�RMI AND COMPLETE.
SWORN TO AND SUSSCRISED BEFORE ME THIS / / r/
DAY OF 20 S'ONATURE PERSON SITTING REPORT
\Dc,/l) U .F.I J
3aGNATURE ^PRINTED NAME j! `
EXPIRES ��
MIY COMMISSION I''3 6V J
MO. DAY TA, AREA CODE DAYTIME TELEPHONE NULDER
PART tI-
If statement is filed on behalf of a Candidate's Authorized Committee,Candidate must sign here.
I SWEAR(OR AFFIRM)THAT TO T',EF FIST OF 1-',I woRw.LE,DGE AU)BELE.:EIS POLITICAL COIM.1 TEE M4 NOT VIOLATED ANY PROVISIONS Or THE ACT OF
.hs c 3,1937(P.L.1333,N4.320)As A:.sNDED,
SWORN TO AND SUDSCRIBED BEFORE Mt THIS
SIGNATURE OF CANDIDATE. .
DAY OF 20
PRINTED NAME
, SIGN/dun
MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NU'ILBER q
NO. DAY YR.
Department of State a Bureau of Commissions,Elections and Legislation
awE.u_cro rl"�nen 210 North Office Building • Harrisburg.PA 1 71 20-0029 • I7171 787-5280