HomeMy WebLinkAboutForbes, Michele - 2021 Annual Report g:17 Pennsylvania Department of State
Bureau of Campaign Finance&Lobbying Disclosure
500 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 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 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.
VERGCO Gttie Committee, Candidate, co Lobby's
Vl� ehthQ _ —ar 62 S
Reporting @A)Name
❑ Cycle 1 0 Cycle 2 0 Cycle 3 ❑ Cycle 4 0 Cycle 5
6th Tuesday 2nd Friday 30 Day 6th Tuesday 2"d Friday
Pre-Primary Pre-Primary Post Primary Pre-Election Pre-Election
❑ Cycle 6 ® Cycle 7 0 Cycle 8 0 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.
01/28/2022
'gn ure of Treasurer, Candidate, or Lobbyist Date (MM/DD/YYYY)
Michele Forbes Camp Hill, PA, USA
Printed Name Location (City/State/Country)
DSEB-502R
• Updated 1/5/2022
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 I.
2- > >.
NUMBER ON BEHALF OF CANDIDATE X COMMITTEE LOBBYIST
NAME OF FILING COMMITTEE,CANDIDATE OR LOBBYIST
Michele Forbes
STREET ADDRESS
2107 Chestnut Street
CITY STATE ZIP CODE
Camp Hill PA 17011 --
TYPE OF REPORT NAME OF OFFICE SOUGHT BY CANDIDATE DISTRICT NO. -PARTY DATE OF ELECTION
(CHECK ONE) dem Mo. DAY borough council
1. 11 02 2a 1
6TH TUESDAY
PRE-PRIMARY FOR OFFICE USE ONLY
MO. DAY YEAR MO. DAY YEAR
2ND FRIDAY 2. DATES OF
PRE-PRIMARY PERIOD NG 12 02 2021 TO 12 31 2021
30 DAY 3
POST-PRIMARY
CASH BALANCE AT END C) n..
6TH TUESDAY 4. OF REPORTING PERIOD.' $ P*4
PRE-ELECTION
TOTAL AMOUNT OF FILER'S r
OUTSTANDING DEBTS OR LIABILITIES 0 XI
FRIDAY PRE-ELECTION r
OF REPORTING PERIOD:AT THE END $PRE OD
B.
POST-ELECTION REPORTS AMENDMENT YES NO X
,.
ANNUAL
TERMINATION St'REPORT X REPORT? YES x
NO .ter '
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 LIABILTI1ES 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 Y KNOWLEDGE AND BELIEF, UE,CORRECT AND COMPLETE.
SWORN TO AND SUBSCRIBED BEFORE ME THIS
DAY OF 20 RS N SUBMITTING REPORT
Michele Forbes
PRINTED NAME
SIGNATURE
MY COMMISSION EXPIRES 717 462-3359
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 20
PRINTED NAME
SIGNATURE
MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NUMBER
MO. DAY YR.
Department of State • Bureau of Commissions,Elections and Legislation
DSL13-503(12-99) 210 North Office Building • Harrisburg,PA 17120-0029 • (717)787-5280