Full Name at Individual tLaat, First, Middle Initial]: er Full Grganiaatien Name

C. Suffelk Bares Int:

 

Mailing Address 55 Allertdn St

 

 

 

Date {If Fleceipl

I El 

1' 'r
05 00 201E
ID 



 

 

City State Ell} Dada
Beaten MA 02119-2901
FEE: IEI nurrider ef 

federal pulilidal eemrnitlee.

 

Name at Empleyer {hr Individual]

Deeupalid-n [for Individual:

 

 

Receipt Fer:
Primary General
Gther [apeeifyt

Aggregate Year-te-Elate 

100000.11]
-

 

Arneunt ef Each [his Peried

100000-00
-

Meme Ilern

Hen-Centdhulien Aeneunt