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  • 1. CERTIFICATIONFORM 2013If you are running in the 2013 elections and you wish to participatein the Campaign Finance Program and be eligible to receive publicfunds, the Certification form must be filed no later than June 10, 2013.Late or incomplete Certifications will not be accepted. Metered mailand other mail without a verifiable postmark will be presumed to havebeen mailed three days prior to receipt by the CFB.File this form tobecome eligible toreceive public funds
  • 2. 2013 CERTIFICATION FORMYou must file this form with the New York City Campaign Finance Board (“CFB”) to become a participant in theCampaign Finance Program (“Program”).THE DEADLINE TO FILE THIS FORM IS JUNE 10, 2013.If you are running in the 2013 elections and wish to participate in the Program and be eligible to receive publicfunds, the Certification form must be filed no later than June 10, 2013. Late or incomplete Certifications will notbe accepted. Limited participants are required to file the Certification with a cover letter stating the candidatechooses to be a limited participant. Metered mail and other mail without a verifiable postmark will be presumedto have been mailed three days prior to receipt by the CFB.IMPORTANT INFORMATION—PLEASE READComplete the entire Certification. Enter “N/A” to indicate items which do not apply. All mandatory fieldshave been marked with an “*”. All pages must be submitted by mail or hand-delivery with originalsignatures of the candidate and treasurer. Incomplete or illegible forms will not be accepted. Anychanges to the information provided require an amendment to the Certification. Contact the CandidateServices Unit at (212) 306-7100 for more information.Communications, both written and oral, will be directed to the candidate’s, treasurer’s, and/or principalcommittee’s address, telephone number, and/or email address.You must notify the CFB of any changes to the information.C-Access is the CFB’s interactive website for campaigns, providing secure online access to C-SMART (CandidateSoftware for Managing and Reporting Transactions), campaign information, and compliance matters. If you havenot previously registered with the CFB for the current election cycle using a Filer Registration form, a C-Accessaccount username and password will be sent to the candidate, treasurer, and voter guide liaison once theCertification has been filed.C-SMART is the CFB’s proprietary web-based software that campaigns are required to use to enter all financialtransactions and electronically submit disclosure statements to the CFB and the New York State Board ofElections (NYS BOE). It is mandatory that email addresses be provided for both the candidate and treasureras part of your registration with the CFB.Campaign-specific usernames, passwords, and an encryption key will be issued to both the candidate andtreasurer upon initial registration.To protect your privacy, the CFB will not provide specific information related to your campaign to any individualor entity not listed on this Certification unless such disclosure is required pursuant to the Freedom of InformationLaw, Article 6 of the Public Officers Law (“FOIL”), or other law.Reminder: Public servants are prohibited from using government resources for their campaigns. Do not list anygovernment phone, fax, email, or address as campaign contact information on this form. Government resourcesmay only be included under “candidate employment” or “treasurer employment” sections (if applicable).New York City Campaign Finance Board40 Rector Street, 7th Floor, NewYork, NY 10006 • Tel.: (212) 306-7100 • Fax: (212) 306-7143/44Website: www.nyccfb.info • E-mail: CSUmail@nyccfb.info
  • 3. 2013 CERTIFICATION FORM1. CANDIDATE NAME AND HOME ADDRESSEnter the candidate’s name, address, telephone numbers, and email address.Note: the candidate’s home address is an address to which legal notices may be sent. You must promptly notify theCFB of any changes.MR. MRS. MS. LAST* FIRST* M.I.STREET ADDRESS* APARTMENT/SUITE/FLOORCITY* STATE* ZIP CODE* DAY TELEPHONE*( )EVENING TELEPHONE( )FAX( )EMAIL ADDRESS*2. CANDIDATE EMPLOYMENTEnter the candidate’s employment information.EMPLOYER NAMESTREET ADDRESS APARTMENT/SUITE/FLOORCITY STATE ZIP CODETELEPHONE( )FAX( )3. OFFICE SOUGHTEnter the office sought, borough or Council district #, and party registration.OFFICE BOROUGH OR COUNCIL DISTRICT #PARTY REGISTRATION (OPTIONAL)4. PRINCIPAL COMMITTEEEnter the committee name, address, New York State Board of Elections (NYS BOE) Filer ID Number, date openedwith the NYS BOE, and other information for the principal committee. The CFB advises against using a P.O. Box foryour committee address. Candidates must authorize and use only one political committee to make expenditures,raise contributions, and receive public matching funds for the 2013 elections. This political committee is thecandidate’s “principal committee.” It cannot have been authorized nor used for any other election, or be theauthorized committee for any other candidate.Note: the committee address is an address to which legal notices may be sent. You must promptly notify the CFBof any changes.COMMITTEE NAME* NYS BOE FILER ID NUMBER*STREET ADDRESS* APARTMENT/SUITE/FLOOR NYS BOE REGISTRATION DATE*CITY* STATE* ZIP CODE* DAY TELEPHONE*( )EVENING TELEPHONE( )FAX( )EMAIL ADDRESS*WEBSITE ADDRESS(ES)*CFB USE ONLYCFB USE ONLYCFB USE ONLYNew York City Campaign Finance Board40 Rector Street, 7th Floor, NewYork, NY 10006 • Tel.: (212) 306-7100 • Fax: (212) 306-7143/44Website: www.nyccfb.info • E-mail: CSUmail@nyccfb.info!
  • 4. MAILING ADDRESS (IF DIFFERENT)If the principal committee’s address is different from the mailing address, enter the mailing address here. Thismailing address will be used for all notices sent to the principal committee.COMPANY OR BUILDING NAME; P.O. BOX (IF APPLICABLE)STREET ADDRESS APARTMENT/SUITE/FLOORCITY STATE ZIP CODE5. PREVIOUS ELECTIONSEnter the previous election(s), if any, in which the candidate sought nomination for election, or election, to publicoffice or a party position.Have you previously been a candidate for any elective office or political party position?* YES NOIf yes, please specify your most recent candidacies below:DATE OF ELECTION (MONTH/YEAR) OFFICE OR PARTY POSITION SOUGHT DISTRICT PARTY PRIMARY ENTERED6. TREASURER NAME AND HOME ADDRESSEnter the treasurer’s name, address, telephone numbers, and email address.Note: the treasurer’s home address is an address to which legal notices may be sent. You must promptly notify theCFB of any changes.MR. MRS. MS. LAST* FIRST* M.I.STREET ADDRESS* APARTMENT/SUITE/FLOORCITY* STATE* ZIP CODE* DAY TELEPHONE*( )EVENING TELEPHONE( )FAX( )EMAIL ADDRESS*7. TREASURER EMPLOYMENTEnter the treasurer’s employment information.EMPLOYER NAMESTREET ADDRESS APARTMENT/SUITE/FLOORCITY STATE ZIP CODETELEPHONE( )FAX( )!!
  • 5. 8. SCHEDULE OF ACCOUNTSList all bank accounts opened by your committee and indicate the type and purpose of the account.Note: a “segregated account” is exclusively for depositing non-matchable contributions for the purposes of: makingcontributions to other political committees; making loans to or spending for other candidates, political clubs, orpolitical committees; payments of expenses for or debts from past elections; and transfers to committees notinvolved in the participant’s current election.PRIMARY BANK ACCOUNT TYPE OF ACCOUNT (SELECT ONE)*CHECKINGSAVINGSMONEY MARKETOTHER (SPECIFY)PURPOSE OF ACCOUNT (SELECT ONE)2013 PRIMARY/GENERAL ELECTION2013 ELECTIONS–SEGREGATEDOTHER (SPECIFY)BANK/DEPOSITORY NAME*CITY* STATE* ZIP CODE*ACCOUNT NUMBER*ACCOUNT NAME (IF ANY)DATE OPENED*DATE CLOSED CURRENT BALANCE*$MONTH* DAY* YEAR*SECONDARY BANK ACCOUNT TYPE OF ACCOUNT (SELECT ONE)CHECKINGSAVINGSMONEY MARKETOTHER (SPECIFY)PURPOSE OF ACCOUNT (SELECT ONE)2013 PRIMARY/GENERAL ELECTION2013 ELECTIONS–SEGREGATEDOTHER (SPECIFY)BANK/DEPOSITORY NAMECITY STATE ZIP CODEACCOUNT NUMBERACCOUNT NAME (IF ANY)DATE OPENEDDATE CLOSED CURRENT BALANCE$MONTH DAY YEARAttach additional form page(s) if the principal committee has more than one (1) additional bank account.DIRECT DEPOSIT OF PUBLIC FUNDSIn order to receive public funds by direct deposit, you must list your ABA/Routing Number found on your committeecheck and attach a VOIDED check from your principal committee’s checking account below. Starter checks will notbe accepted.ABA/ROUTING NUMBER*2013 Election Cycle Checking Account (for Direct Deposit of Public Funds only)Friends of Jane Henley44-22 Roosevelt Avenue, Ste 504Jackson Heights, NY 11372Pay to the order of:ENTER YOUR PRINCIPAL COMMITTEE’SABA/ROUTING NUMBER!
  • 6. 9. UNIQUE MERCHANT ACCOUNTSIf you accept credit card contributions, you must disclose the acquiring bank’s name and your committee’s ownunique merchant account numbers.ACQUIRING BANK’S NAME COMMITTEE’S UNIQUE MERCHANT ACCOUNT NUMBERACQUIRING BANK’S NAME COMMITTEE’S UNIQUE MERCHANT ACCOUNT NUMBER10. CAMPAIGN MANAGER (IF APPLICABLE)If your campaign manager will function as a liaison to the CFB, enter the manager’s name, address, telephonenumbers, and email address.MR. MRS. MS. LAST FIRST M.I.STREET ADDRESS APARTMENT/SUITE/FLOORCITY STATE ZIP CODE DAY TELEPHONE( )EVENING TELEPHONE( )FAX( )EMAIL ADDRESS11A. CAMPAIGN LIAISON (IF APPLICABLE)If you would like a person to function as a liaison to the CFB in addition to the candidate, treasurer, and campaignmanager or consultant (if applicable), enter the person’s name, address, telephone numbers, and email address.MR. MRS. MS. LAST FIRST M.I.STREET ADDRESS APARTMENT/SUITE/FLOORCITY STATE ZIP CODE DAY TELEPHONE( )EVENING TELEPHONE( )FAX( )EMAIL ADDRESS11B. VOTER GUIDE LIAISON (OPTIONAL)You may designate an individual to serve as your Voter Guide liaison. This person will be provided access to theVoter Guide Submission application found in C-Access and be able to help draft and edit your Voter Guide profileand Video Voter Guide script. (The candidate, treasurer, and any other campaign staff for whom you request aC-Access account will be able to access the Voter Guide Submission application.)Note: only the candidate is able to submit the profile and script to the CFB.MR. MRS. MS. LAST FIRST M.I.STREET ADDRESS APARTMENT/SUITE/FLOORCITY STATE ZIP CODE DAY TELEPHONE( )EVENING TELEPHONE( )FAX( )EMAIL ADDRESS12. CAMPAIGN CONSULTANT (IF APPLICABLE)If you have retained a consultant for the purpose of complying with the Program, enter the consultant’s name,address, telephone numbers, and email address.MR. MRS. MS. LAST FIRST M.I.STREET ADDRESS APARTMENT/SUITE/FLOORCITY STATE ZIP CODE DAY TELEPHONE( )EVENING TELEPHONE( )FAX( )EMAIL ADDRESSCONSULTANT ENTITY NAME (IF APPLICABLE)!!
  • 7. 13. ADDITIONAL INDIVIDUAL WITH SIGNIFICANT MANAGERIAL CONTROL (OPTIONAL)The Board’s Rules require that participating candidates, their treasurers, campaign managers, or “persons withsignificant managerial control over a campaign” attend a training provided by the CFB concerning compliance withthe requirements of the Program and use of its software.If someone other than the candidate, treasurer, or campaign manager has “significant managerial control” over thecampaign, list that person’s name and contact information. Note: the individual listed below cannot be the campaignconsultant previously listed in section 12 of this Certification.MR. MRS. MS. LAST FIRST M.I.STREET ADDRESS APARTMENT/SUITE/FLOORCITY STATE ZIP CODE DAY TELEPHONE( )EVENING TELEPHONE( )FAX( )EMAIL ADDRESS14. CONTACT ORDERSelect the order in which you would like the CFB to contact representatives of your campaign. We try to contactyour representatives in the order selected, however if we are unable to reach the individual, we will call or emailthe candidate and treasurer directly. Additionally, certain written notices will be sent directly to the candidate andtreasurer’s home address notwithstanding the order requested.Candidate should be contacted:* First Second Third Fourth FifthTreasurer should be contacted:* First Second Third Fourth FifthCampaign Manager should be contacted: First Second Third Fourth Fifth N/ALiaison should be contacted: First Second Third Fourth Fifth N/AConsultant should be contacted: First Second Third Fourth Fifth N/A15. OTHER AUTHORIZED COMMITTEESComplete this section if the candidate has committees (including any political action committees) that are active andfile disclosure statements with the New York State Board of Elections (NYS BOE) or Federal Election Commission(FEC). Please indicate the name of the committee, the date of the last election in which the committee was involved,office sought, treasurer’s information, date opened with the NYS BOE or FEC, and whether the committee is a jointcommittee.Remember, only the principal committee can be used for the 2013 elections.COMMITTEE NAME LAST ELECTION DATE & OFFICETREASURER’S LAST NAME TREASURER’S FIRST NAMEDATE OPENED WITH NYS BOE OR FEC IF JOINT COMMITTEE, LIST OTHER CANDIDATE(S)DAY TELEPHONE( )EVENING TELEPHONE( )COMMITTEE NAME LAST ELECTION DATE & OFFICETREASURER’S LAST NAME TREASURER’S FIRST NAMEDATE OPENED WITH NYS BOE OR FEC IF JOINT COMMITTEE, LIST OTHER CANDIDATE(S)DAY TELEPHONE( )EVENING TELEPHONE( )Attach additional form pages if the candidate has additional authorized committees.!!!!
  • 8. 5 116. CANDIDATE VERIFICATIONThe candidate must read and initial each clause and sign the Candidate Verification. The candidate’s signature mustbe notarized.I hereby verify that I have not accepted, and I agree not to accept, any contribution or contributionsfrom any one contributor for the 2013 elections that exceed(s) the applicable contribution limit set forthin Section 3-703(1)(f) and (h) of the New York City Administrative Code (“Administrative Code”); that Ihave not used, and I agree not to use, my personal funds or property (or that of my spouse, domesticpartner, or unemancipated children) for these elections, except as contributions that do not exceed thelimit set forth in Section 3-703(1)(h) of the Administrative Code; that I have not made, and I agree not tomake, expenditures in excess of the expenditure limits applicable to the office I am seeking, pursuantto Section 3-706 of the Administrative Code; that I have not accepted and agree to not accept directlyor indirectly any contributions from a corporation or from a political committee not registered with theCFB; that I have not accepted any contributions from a partnership, LLC, or LLP since January 1, 2008,and will not do so; and that I agree to abide by all other applicable requirements of Title 3, Chapter 7of the Administrative Code (the “New York City Campaign Finance Act” or the “Act”) and the CampaignFinance Board Rules (the “Rules”), including requirements for campaign finance disclosure statementsand recordkeeping. initial here*I hereby designate the authorized committee noted in Section 4 of this document to be my principalcommittee for the 2013 elections. The principal committee will submit the campaign finance disclosurestatements required by the Act and will receive all public funds payments for which I qualify in theseelections. The principal committee (i) is the only committee authorized by me to aid or otherwisetake part in the elections covered by this Certification; (ii) is not an authorized committee of any othercandidate; and (iii) has not been, is not, and will not be, authorized or otherwise active for any electionsother than the elections covered by this Certification. I understand that the use of an entity other thanthe designated principal committee to aid or otherwise take part in the 2013 elections is a violationof the Act and will trigger the application to such entity of all provisions of the Act governing principalcommittees. initial here*I understand that I am responsible for reading, understanding, and knowing the contents of the Act andthe Rules. I also understand that I, the principal committee I authorize, my treasurer, and my agents arerequired to abide by the terms and conditions of the Act and the Rules applicable to the 2013 elections,even if amended after I sign this, regardless whether I: meet the requirements of law to have my nameappear on the official ballot for those elections; or meet the threshold for eligibility for public funds; oraccept public funds; or am otherwise not eligible to receive public funds. initial here*I understand that this Certification is a condition for qualifying to receive public funds in these electionsand that other conditions specified in the Act must be satisfied before I may receive public fundspursuant to the Act. initial here*I understand that my home address, the principal committee address and the treasurer’s home address,and email addresses as provided above in Sections 1, 4, and 6 are the addresses to which legal notices,including correspondence and legal papers, will be sent. I further understand that if any of theseaddresses change, I must promptly notify the CFB, in writing, of the change. initial here*I understand that by providing a voided check in Section 8, I am authorizing the CFB to deposit anypublic funds payments my campaign is eligible to receive directly into the indicated checking account.I also grant authorization to the CFB for the full or partial reversal of any deposits to this account in theevent that the deposit was made partly or entirely in error. initial here*I understand that failure to abide by the requirements of the Act or Rules may result in the impositionof such penalties as are provided in Section 3-711 of the Administrative Code and other applicable lawor rules. The Act empowers the Board to assess a civil penalty of up to $10,000 for any violation, whichmay be assessed jointly and severally against me, the principal committee I designate for the 2013elections, the treasurer of that committee, and any other of my agents. I further understand that the Actallows the Board to assess civil penalties exceeding $10,000 against my principal committee and mefor the 2013 elections for failing to participate in the post-election audit process and for spending limitviolations. In particular, the Board may assess a penalty of up to 10% of public funds received by mycampaign for failing to participate in the post-election audit process, and, for spending limit violations, acivil penalty of up to three times the amount the spending limit has been exceeded. I also acknowledgethat the committee I designate for the 2013 elections and I may be jointly and severally liable for therepayment of public funds to the Board. initial here*
  • 9. I understand that if the campaign exceeds the applicable expenditure limit under the Act, in additionto any penalties that may be assessed, the Board may require that all public funds received by thecampaign be returned to the Board, and that the campaign may not be eligible to receive any additionalpublic funds for the 2013 elections. I further understand that if the campaign is required to return anypublic funds for exceeding the expenditure limit, or for any other reason, the principal committee Idesignate for the 2013 elections and I may be jointly and severally liable for such repayment. initial here*I understand that financial control over the campaign is ultimately my responsibility. If any campaignexpenditures are illegal, improper, or not in furtherance of my nomination or election, my principalcommittee and I may be required to return the amount of such expenditures to the Board. In addition,if the campaign does not submit documentation for an expenditure, such expenditure may not beconsidered a “qualified campaign expenditure.” Therefore, I understand that my campaign must followpublished Board guidelines and procedures, employ trained staff, and implement standard financialcontrols and procedures. initial here*I understand that the CFB will issue usernames and passwords to my treasurer and I to be used tosubmit disclosure statements, and that only my treasurer and I may complete the disclosure statementprocess and submit disclosure statements to the CFB. I further understand that my treasurer and I willbe given a single encryption key in order to access campaign data entered using C-SMART. Withoutthe encryption key, we will not be able to access our campaign’s financial data because it is keptin encrypted form. I further understand that my treasurer or I may change the initial encryption keyprovided by the CFB. If my treasurer or I change the initial encryption key and lose that new key, alldata previously entered will be inaccessible. I understand that the CFB will not be able to recover theencryption key or any of our campaign data.initial here*I verify that the information on this document is true and complete to the best of my knowledge andbelief. I understand that intentionally or knowingly making a false statement, including but not limited toin the form of an electronic submission, or intentionally or knowingly violating any provision of the Act, isa Class A misdemeanor pursuant to Section 3-711(3) of the Administrative Code. initial here*I understand that knowingly making a false written statement, including but not limited to in the formof an electronic submission, is a Class A misdemeanor pursuant to New York State Penal Law Section210.45. initial here*I understand that knowingly offering false written information, including but not limited to in the form ofan electronic submission, with the belief that it will become a part of the records of a public office andwith the intent to defraud, is a Class E felony pursuant to New York State Penal Law Section 175.35. initial here*SWORN TO BEFORE ME THISCANDIDATE SIGNATURE*day of, 20NOTARY PUBLIC*
  • 10. 17. TREASURER VERIFICATIONThe treasurer must read and initial each clause and sign the Treasurer Verification. The treasurer’s signature mustbe notarized.As treasurer of the principal committee listed in Section 4 of this document, I hereby verify that I amtreasurer of the only committee authorized by the candidate that will be involved in the 2013 elections.I understand that the use of an entity other than the designated principal committee to aid or otherwisetake part in the 2013 elections is a violation of Title 3, Chapter 7 of the New York City AdministrativeCode (the “New York City Campaign Finance Act” or the “Act”) and will trigger the application to suchentity of all provisions of the Act governing principal committees. initial here*I hereby verify that the principal committee has not accepted and agrees not to accept any contributionor contributions from any one contributor for the 2013 elections that exceed(s) the applicablecontribution limit set forth in Section 3-703(1)(f) and (h) of the New York City Administrative Code (the“Administrative Code”); that the committee has not made, and agrees not to make, expenditures inexcess of the expenditure limits applicable to the office the candidate is seeking, pursuant to Section3-706 of the Administrative Code; that the committee has not accepted and agrees to not acceptdirectly or indirectly any contributions from a corporation or a political committee not registered withthe CFB; that the committee has not accepted any contributions from a partnership, LLC, or LLP sinceJanuary 1, 2008, and will not do so; and that I, on behalf of the committee, agree to abide by all otherapplicable requirements of the Act and the Campaign Finance Board Rules (the “Rules”), includingrequirements for campaign finance disclosure statements and recordkeeping. initial here*I understand that I am responsible for reading, understanding, and knowing the contents of the Act andthe Rules. I also understand that I, the candidate, the principal committee authorized by the candidate,and the candidate’s agents, are required to abide by the terms and conditions of the Act and the Rulesapplicable to the 2013 elections, even if amended after I sign this, regardless whether the candidate:meets the requirements of law to have his or her name appear on the official ballot for these elections;or meets the threshold for eligibility for public funds; or accepts public funds; or is otherwise not eligibleto receive public funds. initial here*I understand that the candidate’s home address, the principal committee address and my homeaddress, and email addresses as provided above in Sections 1, 4, and 6 are the addresses to whichlegal notices, including correspondence and legal papers, will be sent. I further understand that if any ofthese addresses change, I am responsible for promptly notifying the CFB, in writing, of the change. initial here*I understand that by providing a voided check in Section 8, I am authorizing the CFB to deposit anypublic funds payments the campaign is eligible to receive directly into the indicated checking account.I also grant authorization to the CFB for the full or partial reversal of any deposits to this account in theevent that the deposit was made partly or entirely in error. initial here*I understand that failure to abide by the requirements of the Act or Rules may result in the impositionof such penalties as are provided in Section 3-711 of the Administrative Code and other applicable lawor rules. The Act empowers the Board to assess a civil penalty of up to $10,000 for any violation, whichmay be assessed jointly and severally against me, the candidate, the principal committee designatedby the candidate for the 2013 elections, and any other agents of the candidate. I acknowledge that Iam jointly and severally liable for the first $10,000 of any civil penalty assessed against the campaign,including penalties for failing to participate in the post-election audit process and for spending limitviolations. initial here*I understand that if the campaign exceeds the applicable expenditure limit under the Act, in additionto any penalties that may be assessed, the Board may require that all public funds received by thecampaign be returned to the Board, and that the campaign may not be eligible to receive any additionalpublic funds for the 2013 elections. initial here*
  • 11. I understand that the CFB will issue usernames and passwords to the candidate and I to be used tosubmit disclosure statements, and that only the candidate and I may complete the disclosure statementprocess and submit disclosure statements to the CFB. I further understand that the candidate and I willbe given a single encryption key in order to access campaign data entered using C-SMART. Withoutthe encryption key, we will not be able to access our campaign’s financial data because it is kept inencrypted form. I further understand that the candidate or I may change the initial encryption keyprovided by the CFB. If the candidate or I change the initial encryption key and lose that new key, alldata previously entered will be inaccessible. I understand that the CFB will not be able to recover theencryption key or any of our campaign data. initial here*I verify that the information on this document is true and complete to the best of my knowledge andbelief. I understand that intentionally or knowingly making a false statement, including but not limited toin the form of an electronic submission, or intentionally or knowingly violating any provision of the Act, isa Class A misdemeanor, pursuant to Section 3-711(3) of the Administrative Code. initial here*I understand that knowingly making a false written statement, including but not limited to in the formof an electronic submission, is a Class A misdemeanor pursuant to New York State Penal Law Section210.45. initial here*I understand that knowingly offering false written information, including but not limited to in the form ofan electronic submission, with the belief that it will become a part of the records of a public office andwith the intent to defraud, is a Class E felony pursuant to New York State Penal Law Section 175.35. initial here*SWORN TO BEFORE ME THISTREASURER SIGNATURE*day of, 20NOTARY PUBLIC*TOTAL NUMBER OF PAGES SUBMITTED(INCLUDING THE CANDIDATE AND TREASURER VERIFICATIONS)