Blakeney,Paulette_2019-Committee-formsAmendment
Statement of Organization - Candidate Committee ❑ Yes ❑ No
Use this form to create a new or update an existing candidate committee.
This form must be accompanied by forms CRO -3100 and CRO -3500 (when amending., only re -submit if applicable).
1. Committee Information
. Full Name
c. m Number
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b. Mailing Address (include City, State and Zip Code)
d. Date organized
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e. Phone Number
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2. Candidate Information ❑ Candidate's Primary Committee
. F^\ua Name
e. Candidate ID Number
f. Party Affiliation
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(Indicate Nan -partisan if applicable
. Mailing Address (include City, State, and Zip Code)
g. Office Sought
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. Phone Number
d. Email Address
It. Next Election Year
i. Jurisdiction
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Earmail copy of notices
. Treasurer Information
4. Custodian of Books Information
. Full Name
a. Full Name
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. Mailing Address (include City, Stale, and Zip Code)
b. Mailing Address (include City, State, and Zip Code)
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. Phone Number Id. Email Address
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5. Assistant Treasarer laformation Add
. Fug Name ❑ Remove
6. Account Information (inti. CRo-33o0/
Add
❑Remove
a. Financial Institution Full Name
b. Mailing Address (include City, Slate, and Zip Code)
b. Purpose
c. Phone Number
d. Email Address
c. Account Code
d. Type
Email copy of notices
CERTIFICATION
1 certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 22B & 22D -22M of
Chapter 163 of the NC General Statutes and that no funds are commingled with prohibited or other non -disclosed funds.
further certify that this report is complete, We and on I.
Printed Name of Signer Signature of Appointed Treasurer Date
CRO -11M NC State Board of Elections July 2011
NORTH CAROLINA
STATE BOARD OF ELECTIONS
Certification of Threshold
This Certification is used to declare or withdraw a committee's intent to raise or spend $1,000 or less in the
current election cycle.
This Certification is only valid for political party committees and candidates for a county office,
municipal office, local school board office, soil & water conservation district board of supervisors, or
sanitary district board.
This Certification is filed at the Board of Elections office where the committee's campaign reports
are filed.
FILED BY:
Committee Name: C, %w.�
Treasurer Name: 2a�
Treasurer Address: B 11 LckQ V t �w 2
(include city, state, & zip) V . W\ N C
Treasurer Phone: rZ t LA — 6 Z L1 — S') 1� 6
Che One:
I certify that this committee intends to neither receive nor expend more than $1,000 during the current
election cycle under the procedures set forth in G.S. 163-278.10A. This certification will remain in effect
until the end of the election cycle for this committee. If this committee exceeds $1,000 in contributions or
expenditures during this election cycle, I understand that I must immediately notify the appropriate board
of elections and file required campaign finance reports.
THIS DECLARATION CAN ONLY BE MADE AT THE BEGINNING OF AN ELECTION CYCLE.
I am withdrawing my Certification to remain at or under the $1,000 threshold. I will now be required
to file the next scheduled report for all contributions and expenditures that have not been previously
reported from the beginning of the current election cycle. I fu er agree to file all future reports required.
Date Signed Signature
CRO -3600 Cerlifrcalion of Threshold
NORTH CAROLINA
mT� STATE BOARD OF ELECTIONS
Certification of Treasurer
This Certification is used by Candidate Committees to appoint a treasurer for the committee. This form is
required and must accompany the Candidate's Statement of Organization.
This Certification is filed at the Board of Elections office where the committee's campaign reports
are filed.
FILED BY:
Candidate Name: -16A� -�(�.QV\", A
Treasurer Name: G�JznqA
Treasurer Address:
(include city, state, & zip) �p Yl c� „ �\ p �> C 2 g 03
Treasurer Phone: 17 0 u— In 7 4- (,`7 8 U
1 certify that the above information is correct, and I, as candidate, appoint said treasurer to personally fulfill
the duties and responsibilities imposed upon the appointed treasurer and subject to the penalties and
sanctions in Subchapter VIII. Regulation ojElection Campaigns of Chapter 163 of the North Carolina
General Statutes.
I understand that if the above Treasurer changes, it will be necessary to certify a new treasurer and amend
the existing Statement of Organization within 10 days of the vacancy. I further understand that the above
Treasurer is required to receive training by the State Board of Elections within three months of this
appointment according to Article 163.278.9(k).
Date Signed Signature of Candidate
CRO -3/00 Certification of Treasurer
aNORTH CAROLINA
STATE BOARD OF ELECTIONS
Confidential
Certification of Financial Account Information
This Certification is used to report confidential bank account information for all financial accounts
established by the committee and must accompany the Statement of Organization Form.
FILED BY:
�u ' , e� �1 Qe fso('e t^e4\
Committee Name: waw -� p e C� v1Q
Treasurer Name: �o \rQ,,
Treasurer Address: Rli 10 ce v'.* , 1L IZ
(include city, state, & zip) _yAa,6 c . t .M P h) C. -2-gib-5
Treasurer Phone: i py- (o Z -A — S'i $ O
I certify that the information provided below is true and accurate. 1 am providing all account information for the above
named Committee. These account numbers include all bank accounts utilized, credit card accounts, money market or
savings accounts, or any other financial account used for any purpose by the Committee.
The information provided on this form is considered confidential and is not subject to public disclosure. The information
provided is only used for the purposes of an audit or investigation or as required by a court of competent jurisdiction.
Each treasurer (or candidate) must desi¢nate below an account code (any number or letter or combination of
numbers and letters) by which to refer to the account number on reports. If an account number is used as the "account
code," confidentiality of the account number is presumed to have been waived.
The treasurer shall maintain all moneys of the political committee in a bank account or bank accounts used exclusively by
the political committee and shall not commingle those funds with any other moneys.
Type of account Financial Institution Address Account Number Account Code
By signing this statement, 1 authorize agents of the State Board of Elections to inspect all accounts provided.
Date Signed Signature of Candidate or Treasurer
For Candidate Committees Only
/In lieu of providing account information, I certify that this committee will not raise any money nor spend any money
except that which is the candidate's personal funds. I furthermore understand that an audit or investigation could
warrant the probe of any personal bank account that is being used for campaign expenditures.
By signing this statement, I authorize agents of the State Board o lection to inspect applicable accounts.
Date Signed Signature of Candidate or Treasurer
CRO-3500 Cel "li is (Ition of hinancicd : I ccount Inhumation
NORTH CAROLINA
STATE BOARD OF ELECTIONS
Candidate Designation of Committee Funds
This form is used by candidate committees only and allows the candidate to designate in the event of their death,
how the committee's funds are to be disbursed using the eight allowable methods outlined in 163-278.16B(a).
This Designation is filed at the Board of Elections office where the committee's campaign reports are filed.
Candidate Name:
Committee Name:
Treasurer Name:
If Candidate is own treasurer, designate an agent to carry out designations: o C� e r
Committee ID #:
Level Registered: [State] [County] If county, specify:
I, �o.��e 'dW(A+.et , hereby direct that in the event of my death or incapacity all
(Name of Candidate) '
funds remaining in my Campaign Committee account(s) (after payment of permitted outstanding
debts or reasonable expenses for winding up the Committee or closing office) be paid in the
following manner as permitted by N.C. Gen. Stat. 163-278.16B(a).
Name of Entity Plan for Disbursement (eg. Amount or %)
(Select from §163-2 78.168(a))
1. i��.t�h Ct, P-pi,eQ Iboi�
2.
3.
By signing this form, I certify that the foregoing entities are eligible beneficiaries under N.C.
Gen. Statute 163-278.16B(a). A copy of this form should be maintained with the Committee
records.
Signature of Candidate: _ _
Date: I 1- \ of — 19
CRO -3900
Candidate Designation of Committee Funds