SEEC FORM 1 oe ett ‘STATE ELECTIONS ENFORCEMENT COMMISSION Registration by Candidate Revised September 2016 EZ € i 12 uN LOZ ally TREGISTRATIONTVPE [LHIECTIONDATE nea) [oe MUMCTPALI Obit Omens | 70772017 [OFFICE OR FORTTTON SOUGHT COSTRICT NONE Mayor PARTY APRIIATION Okepobican Ooither arty CANODATENANE in rumeide [CANDIDATE RESIDENCE ADDRESS ic CANDIOATENATLING ADDRESS 137 Gest Pain Road Danby fcr fossa [CANDIDATE TETERTONE TE CANDIDATE NATL ADDRES aoa7449s29 sormayor2017egniicom Ti: DESTONATION OF CANPATONFUNDING SOURCE ((Check one) BA. Lam forming a candidate committee and I am required to ile a Candidate Committee Registration Statement Goto Form 1A and complete pages 2 and 3 — Canute Registration Statement DB. Lamexempt from forming a candidate committee and I am fling a Certification of Exemption from Forming 4 Candidate Commitee. Goto Form 1B and complete page 4 — Certation of Rxemtion from Rorming a Candidate Commitee. Important Notice: Failure ofa candidate to complete this page ‘of Candidate Committe,” or Form 1B “Exemption from Forming a Candidate Commit,” with ‘of becoming #candldate will subject the candidate (oa mandatory 100 late ling fe, See Section 9-623(b), Connecticut General Statutes. Mating ale sttement on is jor may sujet ono eriina poles. ling bo Fined imprisonment fo upto ae year afin of wp oe twa lars bal "Wat Sue Hever os thSEEC FORM 1A ‘STATE ELECTIONS ENFORCEMENT COMMISSION Candidate Committee Registration Statement ava September 2016 Obst OAmeninanr | ALAIelsa TCE RANE [ator Mayor 1 COMRATTT ADORERS Ta 1 COMNITTEN EAT, ADDRESS WERSTTE lp. oc 220 Danbury ct ower Zachary s rape (Greta Road or ao oe Danbury ct fossts TREASURER TELERTONE TREASURER EMAIL ADDRES rises ‘achaysrappyatoocom nda l loss 157 Kohanaa test Danbury ict foseio PECDERUTW TREASURER TELETHIONT [25 DEMO TREASURR ENTE ADDRESS a7aans lndabdastvaeactecom Union Savings Bank DEPOSITORY INGTTTUTION ADDRESS Ala oe p= oe M6Main street Danbury Jor fosaroSEEC FORM 1A, ae dott Revised September 2016 ©inior Crrmetnen | Atameids hereby cettyand state, under penalties of ile statement, tha all ofthe designations set forth in this candidate committee registration statement are tue and accurate othe best of my Knowledge and belie, and further, that this statement includes my certification to the fat tht any individual designated herein o serve as my treasurer or deputy teasuror hive indicated to me their acceptance of my appoiniment of them o those positions a Lb y o YlAN7 Thereby certify and stat, under penalties of false statement that have acepted my appoiniment by the candidate to serve as the candidate's designated treasurer ofthis candidate commit. I certfy that Lam an elector inthe State of Connecticut. [intend to comply with all the campaign finance registration and disclosure requizements as contained in Chapter 155 through 157 ofthe General Statutes, and to abide by any prohibitions, limitations or restietons concerning campaign contibutins and expenditures. | certify that have paid any civil penis or forfeitures assssod pursuant to Chapters 155 o 17, inclusive. 1 certify that have not been convicted of or pled guilty or nolo contendere to, in a court of competent Jutsdieton, any (A) felony involving frau, forgery, larceny, embezzlement or bribery, or (B) criminal offense under Title 9 of the General Statues, or hat atleast eight years have elapsed from the date ofthe conviction oF ples or he completion of any sentence, whichever datos later, without subsequent conviction of o plea to nother sich felony r offense. 1 cectify that Lam not otherwise bared fom serving a5 a treasurer by oder ofthe State Elections Enforcement Commission, ygfaere hereby certify and state, under penalties of false statement, tha Ihave accepted my appointment bythe candidate to serve as the candidate's designated deputy treasurer of this candidate committee, and I understand tind accept that, inthe event ofa vacancy caused by the treasurers death, incapacity or resignation, shall Automatically become responsible for discharging ll ofthe duties required ofthe vacating treasurer. {eesti that Tam an elector in the State of Conneticut [intend to comply with al the campaign finanee registration and disclose requirements as contained in Chapter 155 through 157 of the General Statutes, and to abide by any prohibitions, limitations or estietions concerning campaign contributions and expenditures | certify that have pid any civil penis or forfeitures assesed pursuant to Chapters 155 o 157, inelasive {certify that have not been convicted ofo pled guilty or nolo contendere to in court of competent jrisiction, any (A) felony involving fraud, forgery larceny, embezzlement orbebery, or (B) criminal offense ‘under Title 9 ofthe General Statues, o that at least eight years have elapsed from the date ofthe convietion oF ‘es othe completion a any sentence, whichever dates ater, without a subsequent conviction of o pesto nother such felony o offense. 1 ext that Tam not otherwise bared rom serving asa deputy tweasurerby order ofthe State lections Enforcement Commission, 4 Re