Form Cpf M 102 – Fill Out and Use This PDF

Form CPF M 102: Campaign Finance Report

Municipal Form

Office of Campaign and Political Finance

Commonwealth

of Massachusetts

File with: City or Town Clerk or Election Commission

Fill in Reporting Period dates:				Beginning Date:		Ending Date:
Type of Report: (Check one)
		8th day preceding preliminary		8th day preceding election		30 day after election		year-end report		dissolution

SUMMARY BALANCE INFORMATION:

Line 1: Ending Balance from previous report

Line 2: Total receipts this period (page 3, line 11)

Line 3: Subtotal (line 1 plus line 2)

Line 4: Total expenditures this period (page 5, line 14)

Line 5: Ending Balance (line 3 minus line 4)

Line 6: Total in-kind contributions this period (page 6)

Line 7: Total (all) outstanding liabilities (page 7)

Line 8: Name of bank(s) used:

Affidavit of Committee Treasurer:

I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance activity, including all contributions, loans, receipts, expenditures, disbursements, in-kind contributions and liabilities for this reporting period and represents the campaign finance activity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55.

Signed under the penalties of perjury:		(Treasurer's signature)	Date:
FOR CANDIDATE FILINGS ONLY: Affidavit of Candidate: (check 1 box only)

Candidate with Committee and no activity independent of the committee

I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance activity, of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55. I have not received any contributions, incurred any liabilities nor made any expenditures on my behalf during this reporting period.

Candidate without Committee OR Candidate with independent activity filing separate report

I certify that I have examined this report including attached schedules and it is, to the best of my knowledge and belief, a true and complete statement of all campaign finance activity, including contributions, loans, receipts, expenditures, disbursements, in-kind contributions and liabilities for this reporting period and represents the campaign finance activity of all persons acting under the authority or on behalf of this committee in accordance with the requirements of M.G.L. c. 55.

Signed under the penalties of perjury:

(Candidate's signature)

Date:

SCHEDULE A: RECEIPTS

M.G.L. c. 55 requires that the name and residential address be reported, in alphabetical order, for all receipts over $50 in a calendar year. Committees must keep detailed accounts and records of all receipts, but need only itemize those receipts over $50. In addition, the occupation and employer must be reported for all persons who contribute $200 or more in a calendar year.

(A "Schedule A: Receipts" attachment is available to complete, print and attach to this report, if additional pages are required to report all receipts. Please include your committee name and a page number on each page.)

Line 9: Total Receipts over $50 (or listed above)

Line 10: Total Receipts $50 and under* (not listed above)

Line 11: TOTAL RECEIPTS IN THE PERIOD

f Enter on page 1, line 2

*If you have itemized receipts of $50 and under, include them in line 9. Line 10 should include only those receipts not itemized above.

Page 2

SCHEDULE A: RECEIPTS (continued)

Line 9: Total Receipts over $50 (or listed above)

Line 10: Total Receipts $50 and under* (not listed above)

Line 11: TOTAL RECEIPTS IN THE PERIOD

f Enter on page 1, line 2

*If you have itemized receipts of $50 and under, include them in line 9. Line 10 should include only those receipts not itemized above.

Page 3

SCHEDULE B: EXPENDITURES

M.G.L. c. 55 requires committees to list, in alphabetical order, all expenditures over $50 in a reporting period. Committees must keep detailed accounts and records of all expenditures, but need only itemize those over $50. Expenditures $50 and under may be added together, from committee records, and reported on line 13.

(A "Schedule B: Expenditures" attachment is available to complete, print and attach to this report, if additional pages are required to report all expenditures. Please include your committee name and a page number on each page.)

* If you have itemized expenditures of $50 and under, include them in line 12. Line 13 should include only those expenditures not itemized above.

SCHEDULE B: EXPENDITURES (continued)

*If you have itemized expenditures of $50 and under, include them in line 12. Line 13 should include only those expenditures not itemized above.

Page 5

SCHEDULE C: "IN-KIND" CONTRIBUTIONS

Please itemize contributors who have made in-kind contributions of more than $50. In-kind contributions $50 and under may be added together from the committee's records and included in line 16 on page 1.

*If an in-kind contribution is received from a person who contributes more than $50 in a calendar year, you must report the name and address of the contributor; in addition, if the contribution is $200 or more, you must also report the contributor's occupation and employer.

SCHEDULE D: LIABILITIES

M.G.L. c. 55 requires committees to report ALL liabilities which have been reported previously and are still outstanding, as well as those liabilities incurred during this reporting period.