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Home My WebLink AboutFriends of Michele Forbes - 2021 30-Day Post Election 1r Pennsylvania Department of State Bureau of Campaign Finance&Civic Engagement 210 North Office Building,Harrisburg,PA.17120 • 717.7875280(Option 4) l ww--i,c.Gt �i..i:i!?1::1.,,g,i}ttt4d!11.e • r6 stca,-.c.s!Ahan::1-:,.',.curia r.CV 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 re.»-tots or /4 is -1)2-- FOr be 5 Reporting Cycle Name ❑ Cycle 1 ❑ Cycle 2 0 Cycle 3 0 Cycle 4 0 Cycle 5 6th Tuesday 2"d Friday 30 Day 6th Tuesday 2r4 Friday Pre-Primary Pre-Primary Post Primary Pre-Election Pre-Election 8 Cycle 6 El Cycle 7 D Cycle 8 ❑ Cycle 9 30 Day Post-Election f icnnuai'rRepori 12"d Friday Pre-Special'Eiection I 30 Day Post-Special Election j 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 Linder.penalty of perjury under the law of the Commonwealth of Pennsylvania that the accompanying Campaign Finance Report is true and correct. �2�'C� 12/03/2021 Signature of Tre er,Candidate, or Lobbyist Date (DD/MM/YYYY) Ann K. Fields Camp Hill,. PA USA Printed Name Location(City/State/Country) DSEB-502R Updated 1/22/2021 lePennsylvania Department of State Bureau of Campaign Finance&Civk Engagement 210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4) wvok.;7c.5..Fio Kpw .t5nita!2!:trna:;ir • stcar-,, :klti!naa•:�ao^a❑.4'tv Part!I-if this form is submitted with a report by a Candidate's Authorized Committee, the candidate must sign here. I declare under penalty of perjury under the law of the Commonwealth of Pennsyiyania that the accompanying Campaign Finance Report is true and correct. 12/03/2021 Signature of Treasurer,Candidate, or Lobbyist Date(DD/MM/YYYY) Michele Forbes Camp Hill, PA USA Printed Name Location(City/State/Country) • DSEB-502R ilpriated.1/77/?f 21. III I Reset form [ Print Form 1 Commonwealth of Pennsylvania-Campaign Finance Report (Note:This report must be clear and legible.It should be typed) Bier Identification Report Reed By Candidate ❑ Committee Lobbyist Number (Mark X) J� Name of Rare Committee,Candidate or Lobbyist Friends of Michele Forbes Street Address 2107 Chestnut Street City _ Camp NM State PA TIP Code 17011 1 Type of Report(Place x under report type) • 1-6s'Tuesday 2- 211e Friday 3-30 Day Post 4-BmTuesibty 6-2I,Friday 8-30 Day Post 7-Annual Special ri Friday Special 30 Day Pre-Primary Pro-Primary Printery Pre-Election Pre-Election Section Pm-Election Past-Becdon r— 11 ❑ ❑ - ❑ a ❑ L. ❑ Date Of Election Year Amendment ' 'Termind on ❑ (MM/DD/YYYY) 1112/2021 2021 Report Report Summary of Receipts and From Date To date For office Use Only Etpenditures 10/19/2021 11/2/2021 A.Amount Brought Forward llom last Report >f o B.Total Monetary Contributions and Receipts $ too�oo ' (From Schedule i) .� C.Total Funds Available $ 100.00 s . rvi (Sum of Lines A and Eft -.: c v D.Total Expenditures to i (From Schedule Ill) cr S.Ending Cash Balance $ � . (Subtract lire D from line C) 0 4 , �' value of kNGnd Contributions ReceivedI $ o (From Schedule 8) f3.Unpaid Debts and obligations $ (From Scheduler e17.70 cn Affidavit Section Part 1-If this is a Committee report,treasurer sign here.if this is a Candidate report,candidate sign here. I swear(or affirm)that this report,induding the attached schedules on paper.is to the be my knowle and belief, . ect and complete. Sworn to and subucribed before me this day of 30 (�(.� Mniki Fief nature of dut►fFdtdng report Signature Printed Name My Commission mires 717 679-7134 MO. DAY YR. Area Code Daytime Telephone Number Fart II-If this%e a report of a Candidate's Authorized Committee.candidate shall sign here. I swear(or affirm)that to the best of my knowledge and beget this political committee has not violated any prpvlslons of theAdofRine 3,1937(P.L 1333.NO.320)as amended. Sworn to and subscribed before me this day of 20 • 7 ' Signature of Candidate Michele Forbes Signature Printed Name My Commission mires 717 432.3358 MO. DAY YR. Area Code Daytime telephone Number SCHEDULE I Contributions and Receipts Detailed Summary Page Filer Identification Number 11.Unitemized Contributions and Receipts-$50.00 or Less per Contributor I Total for the reporting period (1) $ 2.Contributions of$50.01 to $250.00(From Part A and Part B) I Contributions Received from Political Committees(Part A) $ All Other Contributions(Part B) $ 100.00 Total for the reporting period (2) $ 100.00 I3.Contributions Over$250.00(From Part C and Part 0) I Contributions Received from Political Committees(Part C) $ All Other Contributions(Part D) $ Total for the reporting period (3) $ I4.Other Receipts-Refunds,Interest Earned,Returned Checks,ETC.(From Part E) I Total for the reporting period (4) $ Total Monetary Contributions and Receipts during this reporting period(Add and $ enter amount totals from Boxes 1,2,3 and 4;also enter this amount on Page 1,Report 100.00 Cover Page,Item B) PART B All Other Contributions $50.01 TO$250 Use this Part to itemize all other contributions with an aggregate value from $50.01 TO$250 in the reporting period. (Exclude contributions from political committees reported in Part A.) Filer Identification Number: Full Name of Contributor Date[MM/DD/YYYY] $ Elizabeth M Reilly 11/01/2021 100.00 House# Street Address Date[MM/DD/YYYY] $ 117 S17thSt City State Zip Code Date[MM/DD/YYYY] $ Camp Hill PA 17011 Full Name of Contributor Date[MM/DD/YYYY] $ House# Street Address Date[MM/DD/YYYYJ $ City State Zip Code Date[MM/DD/YYYY] $ Full Name of Contributor Date[MM/DD/YYYY] $ House# Street Address Date[MM/DD/YYYY] $ City State Zip Code Date[MM/DD/YYYY] $ Full Name of Contributor Date[MM/DD/YYYY] $ House# Street Address Date[MM/DD/YYYY] $ City State Zip Code Date[MM/DD/YYYY] $ Full Name of Contributor Date[MM/DD/YYYY] $ House# Street Address Date[MM/DD/YYYY] $ City State Zip Code Date[MM/DD/YYYY] $ Full Name of Contributor Date[MM/DD/YYYY) $ House# Street Address Date[MM/DD/YYYYJ $ City State Zip Code Date[MM/DD/YYYY] $ SCHEDULE IV Statement of Unpaid Debts Use this Section to itemize all unpaid debts and obligations which are outstanding at the end of the reporting period. Filer Identification Number: Name of Creditor Robert Forbes Outstanding Balance of Debt House# Street Address DATE DEBT INCURRED $ 2107 Chestnut Street [MM/DD/YYYY] 10/16/2021 City Camp Hill State Zip PA Code 17011 617.70 Description of Debt loan for signs,door hangers,flyers,cards Name of Creditor Outstanding Balance of Debt House# Street Address DATE DEBT INCURRED $ [MM/DD/YYYY] city State Zip Code Description of Debt Name of Creditor Outstanding Balance of Debt House# Street Address DATE DEBT INCURRED $ [MM/DD/YYYY] City State Zip Code Description of Debt Name of Creditor Outstanding Balance of Debt House# Street Address DATE DEBT INCURRED $ [MM/DD/YYYYJ City State Zip Code Description of Debt Name of Creditor Outstanding Balance of Debt House# Street Address DATE DEBT INCURRED $ [MM/DD/YYYYJ City State Zip Code Description of Debt Name of Creditor Outstanding Balance of Debt House# Street Address DATE DEBT INCURRED $ [MM/DD/YYYY] City State Zip Code Description of Debt