Bivens,Margaret_2025-Waivervo'l NORTH CAROLINA
STATE BOARD OF ELECTIONS
Mailing Address Phone
P.O. Box 27255 (919) 814-0700 or
Raleigh, NC 27611-7255 (866) 522-4723
AFFIDAVIT TO
REQUEST A WAIVER OF
CIVIL LATE PENALTIES
PAGE 1 OF 2
JHiv U y
• A political committee or referendum committee requesting a waiver of a civil late penalty and c S.l§163-278.34(a)
must complete and file this form with the State Board of Elections. 08 NCAC 21 .0206.
• The form must be filed within 60 days of service of the notice of penalty assessment. 08 NCAC 21 .0206.
• The State Board may waive a late penalty if it determines there is good cause for the waiver. Please include all relevant
fads or circumstances on this form. You may attach additional pages if necessary.
• An affidavit is a statement given under oath that its contents are true and accurate. By signing this affidavit form, you
swear, under penalty of perjury and other penalties established by North Carolina Law, that the information provided in
this affidavit is true, correct, complete, and of your own personal knowledge.
• Please note, this form will be disclosed to the public as provided in the North Carolina Public Records Act.
• The form maybe filed by mail to: NC State Board of Elections, PO Box 27255, Raleigh, NC 27611-7255, or by email to
campaign.reporting@ncsbe.gov. f you choose file by email, an original signed copy of the form must be retained for at
least two years counting from the date of the election to which the late report affects. 08 NCAC 21 .0206.
• For more information, please review 08 NCAC 21.0206 or visit the State Board of Election's website at www.nc5be.gov.
1
Information
About You
Margaret Cox Bivens
Name
603 Washington St.
Address
Marshville
City
E -Mail Address
NC
28103
State Zip Code
704-624-2413
Telephone Number
2 Margaret Cox Bivens being duly sworn, stated:
Sworn Affidavit Name
1. 1 am over 18 years of age, of sound mind, and I have personal knowledge of the facts stated herein.
2.1 am a resident of Union County of NC
County and State of Residence
3. 1 am the: ❑+ Authorized Candidate for ❑ Treasurer of
❑ Chairof ❑ Vice -Chair of
❑ Secretary of
Committee To Elect Margaret Cox Bivens
Name of Committee
�l NORTH CAROLINA
2
Sworn Affidavit
(Continued)
STATE BOARD OF ELECTIONS
AFFIDAVIT TO
REQUEST A WAIVER OF
CIVIL LATE PENALTIES
PAGE 2OF2
4. The committee was assessed a penalty by the North Carolina State Board of Elections on
/d of 3 a 2024
Dote of Penalty Report Year
1 Aij 0 9 2025
RECENEG
❑ First Quarter Report
❑ Second Quarter Report
❑ Third Quarter Report
❑ Fourth Quarter Report
❑ Mid -Year Semiannual Report
❑ Year -End Semiannual Report
❑✓
Mid -year semiannual
Municipal Report
5. On behalf of the committee, I am formally requesting a waiver of the penalty described in
paragraph 4.
6. Please describe all facts and circumstances you would like the State Board ttoconsider in
reviewing your waiver request. Attach additional pages if�nje/c�e,�sis�G""'_.
�' -zt,l � ` �,f,.,��� � `�(iC/, /x'%7 "6.
7. The facts and circumstances described in this affidavit are true and accurate to the
best of my knowledge.
X
ftnatur(r&
Jurat Signature of Affiant
State of North Carolina, County of ��orI DY)
Sworn to Lqr affirmed) and subscribed before me,
This day of 20_�
Signature of No Publ :
_4
Printed Name of Notary Public:
My Commission Expires
Date
- bltliR7CFltiUtMUA
NOTARY PUBLIC
Union County, North Carolina
My Commission Expires 9/2/2029