HomeMy WebLinkAboutFriends of Jake Miller - 2021 Annual Report Pennsylvania Department of State
Bureau of Campaign Finance&Civic Engagement
Ify
210 North Office Building,Harrisburg,PA 17120 • 717.787.5280(Option 4)
www.dos.pa.eov/camnaianfinance • ra-stcampaienfnance@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 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
Friends of Jake Miller
Reporting Cycle Name
0 Cycle 1 0 Cycle 2 0 Cycle 3 0 Cycle 4 0 Cycle S
6th Tuesday 2nd Friday 30 Day 6th Tuesday 2nd 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 1-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.
_At ),3/c21
Si: e of Treasurer, Candidate, or Lobbyist Date (DD/MM/YYYY)
J. -ssica Beamesderfer Camp Hill, PA 1701 (
Printed Name Location (City/State/Country)
DSEB-502R
Updated 1/22/2021
Pennsylvania 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/campaiunfinapce • ra-stcamoaienfinanceapa.eov
Part!!_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 Pennsylvania
that the accompanying Campaign Finance Report is true and correct.
i029
Signature.of Treasurer, Candidate, or Lobbyist Date(DD/MM/YYYY)
Jake Miller Camp Hill, PA 170 (
Printed Name Location (City/State/Country)
•
DSEB-502R
Updated 1/22/2021
CAMPAIGN FINANCE'STATEMENT
File this in lieu of a full report only If aggregate,r..ecteipts., expenditures,or
liabilities incurred.each'did not:exceed$250.0.0.during'the reporting period. '
PAER.IDQNTIRCATOM .. REPORT'►S.tlD TF 1 .. 1. 2 :
3.
NUMBER 'gNBBFlA4P OR :CDibA . COMMIi"lEF_ 98Y}$'i'
NALGO GLOM COiMFITTIM,CANDIDATE OR LOBE •
fil)A4171S kt• 141lGa. . . .
STREET ADDREE¢
7o ; it .�'?a . • .
CITY STATE VP CODE
ilifitkArit 1 L . TA 7"/�
. .-_.
TYPE OF REPORT NAME OOF CE SOUGHT BY CANDIDATE DISTRICT'NO. PARTY DATE OF ELECTION
• (CHECK ONE) • LIMO: ;:iIAY... A, '
...0 ePJtl#4,i. s '.FOR:OFFICE'..USE:ONLY
:,A;;%i= .{.:'rbi'�<': MD^ ':,DAY ,,.;YEAR ''MD :DAY:..`:YEAR. - .
`•2N ,''F it • 2. DATES OP ) ry .
p.. ':' REPORTING 0 1 01 I2 oa( T° 12 I
:: 'FIAITA1ttY P!!Rt t! 1V/ avai
ODA. ....:.'.f.. .3. -
Y`''y'. n a
'P�: MARJ.. . .
:.•::!il .:,• sir;.>'! CASH BALANCE AT END 0 C_
OF REPORTING PERIOD: + '
":` >'::::`': _ TOTAL AMOUNT OF FILER'S I..'.s
r:" •'' "'- ` ' s OUTSTANDING DEBTS OR LIABILITIES. �.r
AT THE END OF REPORTING PERIOD: $ /D O > •
'c•§S 0Iiil¢lWN.'.'.• :.A AENDMENT:.' YES NO
'd NaU :; ` - - / ..:TERMINATION: ./
'RF_POItT <; �{// 1'ES NO VV
REPORT `;.:•
•
AFFIDAVIT SECTION
PART(, .
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 mtist sign here. •
(;.SWEAR(OR AFFIRM)THAT THE AgDREBATE RECEIPTS OR DISBURSEMENTS OR'LIABIUTTES INCURRED DURING THE REPORTING PERIOD.INDICATED ABOVE DID NOT .
pXr'ED TWO HUNDRED AND FIFTY DOLLARS($250.00)AND THIS REPORT IS,TO THE BEST.OF MY KNOWLE.c 'ND BELIEF,TRUE,CORRECT AND COMPLETE.
• SWORN TO AND SUBSCRIBED BEFORE ME THIS
r
• 20 S LITE OF PERSON SUBMITTING REPOTDAY OF •
• • t G Qn ,p / • •
• SIGNATURE PRINTED NAME
MY COMMISSION.EXPIRES
_Id_ 5(if -a Io 1 .
• A
MO. DAY YR. A CODE DAYTIME TELEPHONE NUMBER
PART II-
if statement is filed on behalf of a Cqndidate'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 VICV'TED ANY PROVISIONS OF THE ACT OF
JuNE 3,1937(P.L.1333,No.320)AS AMENDED.
SWORN To AND SUBSCRIBED BEFORE'ME THIS _ •
• )1(71NA.
RE OF CA. yATE
DAY OF 20 • � A1�/f, e.PRINTED NAME 1 6.
:SIGNATURE I(1 15/a Q341 y
MY COMMISSION EXPIRES AREA CODE DAYTIME TELEPHONE NUMBER
MO. . DAY YR.
Department of State I Bureau of Commissions,Elections and Legislation
DSEB-503(12.99) 210 North Office Building • Harrisburg,PA 17120-0029 • (717)787.5280