HomeMy WebLinkAboutUpper Allen Mech. Democratic Club - 2021 30-Day Post Election vilPennsylvania 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.gov
Unsworn Declaration in Lieu of Sworn Statement for
Campaign Finance Statements
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).
h's rdcu ar --is-to-be-used-only for-Campaign Finance Statements. This form must be
signed by hand where a signature is required.
Name of Filing Co] /mmittt�ee, Candidate, or Lobbyist
G,Wy 4/ /�" edon/c,E3UY - ' ox4-G i!.,G 46
Reporting Cycle Name
❑ Cycle 1 ❑ Cycle 2 ❑ Cycle 3 ❑ Cycle 4 ❑ Cycle 5
6th Tuesday 2"d Friday 30 Day 6th Tuesday 2"d Friday
Pre-Primary Pre-Primary Post Primary Pre-Election Pre-Election
Cycle 6 ❑ Cycle 7 ❑ Cycle 8 ❑ Cycle 9
30 y 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 accompanying Campaign Finance Statement is true and correct.
ZI)arift4/ 21 0 r 202/
Signature of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY)
12lIM Lti ly �,/tithl frke-A07; 091 PIIIZO (44
Printed Name Location (City/State/Country)
DSEB-503S
Updated 1/22/2020
9
Commonwealth of Pennsylvania Iflllllllllliflihflllllllllllllllllllllllllllllllilflgll
Campaign Finance Statement 359166
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 NUMBER: 20190208 REPORT FILED ON BEHALF OF: Committee
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST UPPER ALLEN MECHANICSBURG DEMOCRATIC CLUB
STREET ADDRESS 2138 CANTERBURY DRIVE
CITY MECHANICSBURG STATE PA ZIP CODE 17055-5767
TYPE OF REPORT 30-Day Post-Primary
NAME OF OFFICE SOUGHT BY CANDIDATE
DISTRICT CODE PARTY CODE R C
DATE OF ELECTION 11/2/2021 f"' C")
------ •s.rr RcrvniiZ4 lr/- G1 Ter; 11/2Lr2t121 "For vVfi'rce Use Only
AMENDMENT REPORT? NO TERMINATION REPORT? NO :")
CASH BALANCE AT THE END OF REPORTING 2,158.42 (�)
PERIOD: ,E"
TOTAL AMOUNT OF FILER'S OUTSTANDING 0.00
DEBTS OR LIABILITIES AT THE END OF
REPORTING PERIOD:
AFFIDAVIT SECTION
PART I-
If statement is filed on behalf of a Political Committee or Candidate'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 MY KNOWLEDGEOf4H1R/01/AND BELIEF,TRUE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS day of 20
SIG PEII.S2A.SUBMITTING REPORT
�1N1 i�Lib Y e
SIGNATURE PRINTED NAME
V/ Gb3296C
MY COMMISION 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 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
day of 20
SIGNATURE OF PERSON SUBMITTING REPORT
SIGNATURE PRINTED NAME
MY COMMISION EXPIRES MO. DAY YR.
AREA CODE DAYTIME TELEPHONE NUMBER
Department of State.Bureau of Commissions,Elections and Legislation 11/24/2021 7:58:15 AM
210 North Office Building.Harrisburg,PA 17120-0020.(717) 787-5280