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� Form CPF M 102-0: Campaign Finance Report
Municipal Form
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cny or Town ot: � �� 1009 APA 28 A � 3 �
Pleaze print or type all infortnation,except signa[ures.
fill in datts: Mo th D y Year Month D�y2 Ye�.a�
Reporting Petiod Beginning ,�Q�1 �7 Ending � /�f � !�
Type of Repon: (Check One)
� 8th day preceding � 8th day preceding election 'f 30th day following elettion � 20th day of lanuary
Ipreliminary/primary (Town or Special) (Year-End Report)'
Pursuant to M.G.L.,Chapter 55:
I�. 1 cercify that 1 am a candidate for or hold Municipal Office.
2. I mrtify tha[!have not received any contribucions,made any expenditures,or incurred any obliga[ions during this
reporting period,and do not have a campaign fund in exisience.
3. 1 rertify that 1 do not have a poli[ical committee.
DATE L SIGNATURE IL RESIDENTIAL ADDRESS 111. OPFICE SOUGHT
Signed under the penalties of perjury (Snee[and Number)
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