Please print form and submit original signed form to the Town Clerk's Office following electronic submission.

This form is for the use by a candidate that has not accepted any contributions, or had any monies spent on his/her behalf, and has not spent any personal funds to promote his/her candidacy.

TODAY'S DATE (xx/xx/xxxx):*

CANDIDATE NAME: *

Address: *

City:*

State:*

Zip:*

REPORTING PERIOD:

Beginning Date: (xx/xx/xxxx)*

Ending Date:(xx/xx/xxxx)*

CONTRIBUTIONS RECEIVED DURING THIS REPORTING PERIOD
$0.0

EXPENDITURES MADE OR INCURRED DURING THIS REPORTING PERIOD
$0.0

I affirm that neither I, nor any other person, received contributions on my behalf nor made any expenditures on my behalf during this reporting period.

Candidate signature: _________________________________________________

Date: ___________________

NOTE: After hitting "Submit and Print", use Internet print function to print page, then MUST HIT "CONTINUE" to submit electronically.

Submit original signed form to Town Clerk after submitting electronically