HomeMy WebLinkAbout2023 Verrier - Statement of Organization � Form CPF M101: STATEMENT OF ORGANIZAT�� � V E D
CAND[DATE OR CANDIDATE'S COMMI'I17'E'�!*,' � �E R K
MUNICIPAL FORM � ' ' ' ' .= �AA.
co�„�,o����roi�i, Office of Campaign aod Political btinance Z(lf �j�� LZ P 2 37
of Mesechusm��
Filcwitk City;TownClerkarLleclianCanvnisslon
NOTiCE IS HGNFBY GNEN in accocdance with thc pcovisions of Genera!Laws,Chaptcr 55,as amended,organization ofa candidatc or
eandidate's committec as follows:
CANDIDATE: F�IINamc�.
ResidemialAddress: ��' ���'�'�I�+�N �
Ciry/S�ate/Zip: L �
e-Maunadress: WI�V1Pt�'e P,✓VIeV/�9 ('YYYA��y� rno��a �Qj�'�{�—r1Z�
Party ACGlia�ion: (I[applicable)
OFFICE SOUGHT/PURPOSE:
Tille- �� � ���r(A T��� DistncL
CnndidatewithoWeommlttee(ch kifapplicable) fce<ked,donoteomplereeommineeorofiiee�secnons:signascandlde�e,
� dete and filc with cicrk or lowl dcc�ion officfal.
COMMITTEE: ne�»eorcom�„hm��. m _ ��P�
�Thc namc of thc mmmirzee�nus�include the wndidetc's lest neme)
Commiucc MaiGng Addrese: �1 �1 I.n n 1„��I � /� „� �
J vK-F.,VI 4-lN0.Y—
Ciiy/Siaic/Zip�. ��� IA� Y}'��] A � �10'7 PhoneA: �81 � ��—���
WL � � 1J l
OFFICERS:
Chairperson: �t� Treasurer': "r
Re.iJen�ialnddresr � 11�h�n�. � Residemialdddress�. � K11 /���p� �
Ciiy/State/ZIP: �/�� �_ GtY/5�a�e/Zip: �Q� �� . �Ad� Q�
Phone#'. I _ 7. ^ J.J�j. rn��eu�. �D��-'�3 Z3l$ma�i: v�r� COrneas�"
"J /'
'A ublicein lo�eema notscrvcas¢eam rotxn ofiticelcommirzee seeveverse.
Addicional officcrs may bc lisma on pagc�wo- e
Che applicablc box bcCore signiug:
Candfdetc with wmmiaee: I hereby q wnsenl to this fli�g;2)undersland Ihel a candidatc shall�o�consent to�hc o�ganizatiov oCmore thnv oue accow�
or mmiacc o�thcrz bchalf,3)am subject lo cerlain duties and liabililizs under M.QL a 55,ivclodivg the iimely filing ofcampaigo fmanw�cports and
keepivg detailed accounts avd mwods of ell eempafgn fnn�ec ac�iviry fo�a pe�iod ofsix years from�he dn[c of�he relevaut election;avd 4)may noi serve as
¢cawre�of a political wmmiuee o�ganized on my behalf.
❑ Candidete without committcc I hcrcby 1)wosem ro thls 61Iug;2)u�de�stavd thal a candidnre shell no�consenno ihe o�gavizafio�of mo�e�hau one
eeoo�m o�commiveeov their behalf;3)acknowledge iCl bewme e pubfic employec 1�nuero�gavize a wmmittec and�ney no�serve as t�eaeumr;end 4)em
subject[o ecrtein d�hes avd IiebiGfies�ude�M.G.L.c.55 ivcludivg�he nmely filing o(cempuign fivauw repons a�d keeping deqiled aocouuts a�d records of
ell campaign flvance activity for a pcnod oP six ycers from thc datc of thc relevaut elutio�.
SIGNED UNDER THE PENALYIGS OF PERJURY: ( /1 �.��1 / v `� Date: 22 2
Candidn�c's signawm
I hercby acccp��hc office ofTreasurer ofthe above-named comminee. 1 affimi that I am no�a Oublic cmployce as defined by M.QL.a 55,s. 13.1 ondersland
thaL p I am aubject to cenai�doties a�d liabilities ondec MQL.a 55, ineludfng[he timely 51ing of campaign fnance mports a�d keepiug de�ailed aeeo�ntv
and records of all cempaign fi�ance acnvity fo�a pedod ofsiz years from�he datc hc�cJwantcicefion;2)if afier my acce��anec ofMls offse 1 become an
appoinled public employee,I most oesiyn�his position and notify OCPF of nry� �atio/',and 3)a candidalc may m[scrvc as��easu�er of�hc poG��cal
commi[tcc organized on their behalf.
�
o-ie: ���/d3
SIGNCD 71NDER THE PENALTIBS OF PERIURY: Trc cr'CsignaNre
Ihcmbyacoep[[heofficeofCha¢persanof�heabov�uamed mmitree.
SIGNED UNDER THE PENALTIES OF PERJURY � Data/`)�J�J J'/�
1
Chairye�sou's si�m 1��