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SCHEDULE A: RECEIPTS
M.G.L. a 5�regurres!ha!the name and residenlial address be reported, in alphabetical order,jor al1 receipts over$50 in a calendm
year. Commf[lees must keep detai(ed accounts and remrdr ofa[1 receipm�, 6i<t need only iiemize(hose receip(s over 550. In addifian, (he
occupafion and employer mesl be repor(ed jor all persons who contribr�te 5200 or more in�calendar year.
(A "Schedale A: Receip[s" a[[achmenf is available to complete,print aud a[[ach to this repor[,ifaddi[ional pages are required to
repor�all reeeipts. Please include your committee name and a page nomber on each page.)
Name aod Residential Address Owapation & Employer
Da[e Received (alphabetical listing required) Amoun[ (for con[ributione af$200 or more)
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Line 9:Total Receip[s over$50(or listed above) �
Line 10:Total Receip[s$50 and underx(no[listed above) �
Line 11: TOTAL RECEIPTS IN THE PERIOD � E- Emer on page I, line 2
' Ifyou have iiemized receip[s of$50 and under, include them in line 9. Line 10 should include only[hose receipLs nol i�emized above.
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SCHEDULE A: RECEIP7'S (contioued)
Name and Resideotial Address Occupatioo & Employer
Date Received (alphabetical lisfing required) Amouo[ (for contributioos of$200 or more)
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Line 9: To�al Receipts over$50(or lis[ed above) �
l.ine 10:Total Receipts$50 and under' (not listed alwve) �
Line 11:TOTAI,RECEIPTS IN THE PEIiIOD � f Enter on page I, line 2
' Ifyou have itemized receipis ofS50 and under, include them in line 9. Line 10 should indude only those receipts mt itemiud above.
Page 3
SCHEDULE B: EXPENDITURES
M.G.L. a JJ requires ennrmineer[o list, in alphabetica!ardeq a/l ezpendllures aver S50 in u repurfittg period. CnmmR(ees mus(keep
detniled acmunts and remrd.+'nfr�/(eependiture.q bae!need wvh�rtemice[/vose over 550. Ezpenditrmes$50 and under mtry be odded mgether,
fi�om committee mcorrG, and repmYed on line [3.
(A "Schedule B: F.xpenditures" attachment is available to comple[e, prin�and allach to[his report, if additional pages are required [o
report all expenUimres. Please include your commitree name and n page number on each pnge.)
To Whom Paid
Date Paid (alpha6eticallistinpJ Address Purpose of Expenditure Amoun[
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Line 12: Total ExpendiNres over$50(or listed above) �3.
Line 13: Total Expendi[ures$50 and under' (not listed above) �
Enrer on pege I,line 4 + Lioe 14:TOTAL EXPENDITURES IN THE PEAIOD �39
* Ifyo�have i[emized eapenditures of$50 and under,include them in line 12. Line 13 shoWd include only those expendiaws not icemized
above. Page d
SCHEDULE B: EXPENDITURES(continued)
To Whom Paid
Datc Paid (alphabefical listiog) Address Purpoae of Expenditure Amount
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Line 12: EzpendiNres over$50(or lisled above) �
Line 13: ExpendiNres$50 and under'(no[lis[ed above) �
Enrer on page I,li�4-� Line 13:TOTAL EXPENDITURES IN THE PERIOD �
' If you have item'ved expendimres of S50 and under,include them in line 12. Line 13 should include only those expendiN�es not itemized
above.
Page 5
SCHEDULE C: "IN-KIND" CONTRIBUTIONS
Plcase itemizc contributors who have madc imkind contributions of more[han $50. In-kind contributions $50 and under may be
added together from the wmmittee's rewrds and included in line 16 on pege l.
Da[e Received From Whom Received* Residentlal Address Descriptlon of Cootribafion Value
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Line 15: In-Kind Contribu[ions over$50(or listed above) �
Line 16: In-Kind Contributions$SO& under(not listed above)�
Enrer on page I,line 6 -� Lioe 17: TOTAL IN-KIND CONTRIBUTIONS �
• If an in-kind contribu[ion is received Crom a person who conhibu[es more than$50 in a calendar yeer,you must report the name and address
ofihe contribotor:. in additioq ifihe contribmion is 5200 or more,you must also repon ihe contributots occupation and employec Page 6
SCHEDULE D: L[ABIL[TIES
MGl. c. 55 requires canrnriltees m report�ILL licrbilitiev which have been reported previnusly ond are s[II/outstanding, ns wel/
as tho.se liabi/ities incurred during this reporli�ig period.
Date Incurred To Whom Due Address Purpose Amoont
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Gler on page 1,line 7-� 1.ine IS: TOTAL OUTSTANDING LIABILITIF.S(ALL) �
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