No preview available
Broadaway,Jeffrey_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 accom anied b% forms CRO -3100 and CRO -3500 when amending. only re-suhmit if a>. licahle . am 1. Cdlatimittee Information . Full Name c. ID Number . Mailing Add (include City, State and Zip Code) d. Date Organized Phone Number . Candidate Information ❑ Candidate's Primary Committee . Full Name Jc f l3� �/or- ,8�� e. Candidate ID Number E Party Affiliation 4.0� s /"61,144,- (Indicate Non-partisan if applicable b. Mailing Address (include ( ity, State, and Zip Code) OU, / df- 41/ vNl"Wl ^/L d1111) g. Office Sought UN/0i1V1 SIG Town. 6 r>•fn. A0'bnar . Phone Numberpn d. Email Address Is. Next Election Year t. Jurisdiction []Email copy ofnot-k 7 -Treasurer Information 4. Custodian of Books Information . Full Name a. Full Name b. Mailing Address (include City, State, and Zip Code) - b. Mailing Add and Zi Code) MSD JU . Phone Number d. Email Address c. Phone Numberl Id. Email Address lon Co. Elections 1 prefer to receive notices by email LJ Yes U No Email copy of notices 5. Assistant Treasurer InformationAdd . Full Name ❑ Remove 6. Account Information (incl, C20-3500) Add a. Financial Institution Full Name ❑ Remove b. Mailing Address (include City, State, and Zip Code) b. Purpose c. Phone Number d. Email Address a Account Code d. Type Email copy of notices ERTIFICATION I 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. 1 further certify that this report is complete, true and correct. jefFvey J8. Vevattfryc4y -dze ILip /a Printed Name of Signer tat of Appointed Treasurer O Date CRO -2100A 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: Treasurer Name: Treasurer Address: (include city, state, & tip) Treasurer Phone: ✓ t" Ko- MZ. .t i//o Cheek 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. 1 further agree to file all future reports required. Date Signed Signature CRO -3600 Certification of Threshold PTH CAR ELECTI 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: Treasurer Name: Treasurer Address: (include city, state, & zip) Treasurer Phone: Jt#�el. /F. 8.7"4 70`f- LLI- of7- I 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 V111. Regulation of Election Campaigns of Chapter 163 of the North Carolina General Statutes. 1 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). ?- /gyp//9 DJAf J 2. Date Signed Signature of Candidate CRO -3100 Certification of Treasurer © NORTH CAROLINA VOTE r1TT� 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: //��^^ /, /� Committee Name: tfe X a.y A4pp /J&Z Treasurer Name: ticff/, .v • 96WAt, H !D Treasurer Address: 3 L 1 (include city, state, & zip) am vUG NZ, d 0 l/o ` `- {�b D Treasurer Phone: —Off JUL 2 6 2019 1 certify that the information provided below is true and accurate. I am providing all aci I we 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 designate 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, I 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 of Elections to inspect applicable ac nts. X41 /1 i�..� R. )?, =Z -� Date Signedtat a of Can idate or Treasurer CRO -3500 Certification of Financial Accmmt lnJormation