Coffey,Valerie_2023-Committee-formsStatement of Organization - Candidate Committee Is this statement:
❑ New ❑ Amended
Use this foam to create a new or update an existing candidate committee.
This form must be accompanied by form CRO -3500. An amended form is required for each new election vent.
. Com ee Information
e f Co mittee
d. ID Number
lj /n , 61
. M _ _(include Cht Ott_ _ Cod _
e. Date rg _
. Committee Website (Optional)
I. Phone Number
. Candidate Information
. F .gate
e. Zlirly Affiliation
. Malting (Include City, State, and ode)
ce Sought
Address
.Phone Number d. Email Address
.Next Election Year
h. Jurisdiction
�*-493vfft
Email co of re ort notices
3. Treasurer Information
4. Assistant Treasurer Ino tion
a. Full Name
VName /y
e- Se -i
MaWmtg Address (include City, State, and ZipCodt)
. Mailing Address (bu)adt City, State and Zip Code)
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��41e&) 110
c. Phone Number
14. EmaB Address
c. Phone Number
d. Email Addrers
Send re ort notices by email L1 Tes No
Email copy of reon notices
5. Custodian of Books Information (Keeper of Records
6. Account Information (mel CRa3500)
a. Full Name
a. Financial Institution Fall Name
h. Mailing Address (include City, State, and Zip Code)
. Phone Number
d. Email Address
b. Account Code
c. Type JUL A
Union Co. Elections
❑ Email copy of report notices
1 certify that the Committee is in compliance with all applicable provisions of Article 22A of Chapter 163 of the NC
General Statutes and that no funds are commingled with Inhibited or other non -disclosed funds. I further certify that
th1i port is complete, true and correct.
4
Xppomt9fTA6urW bate
Printed Name of Treasurer Signature
of
1 certify that the information above is correct, and 1, as the candidate, appoint said treasurer to personally fulfill the
duties and responsibilities imposed upon the appointed treasurer and subject to the penalties in Article 22A of Chapter
163 of the NC General Statutes.
is a�
Printed Name of Candidate I
Signature of date D to
CRO -2100A NC State Board of Elections November 2019
VOTE
�n,11i
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 fled 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, & zip)
Treasurer Phone:
Yectlk One:
Icertify that this committee intends to neither receive nor expend more than $1,000 during the current
on cycle under the procedures set forth in G.S. 163-278.1 OA. 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.
�,_ 1 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 fur er ag ee to file all future reports required.
Date Signed signature
CRO -3600
Cerrificarion of Threshold
NORTH CAROLINA
STATE BOARD OF ELECTIONS
Con dentia!
Certification of Financial Account Information
This Certification is used to report confidential bank account information for all financial accounts
established by the committee d must accompany the Statement of Organization Form.
FILED
Committee Name:
e
Treasurer Name:
Treasurer Address:
(include city, state, & zip)
Treasurer Phone:
I certify that the information provided below is true and accurate. I 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 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:
JU� 12 023
By signing this statement, I authorize agents of the State Board of Elections to inspect all EeWctiolls
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 si ning this statement, 1 authorize agents of the State Boo ctions� nspec ficabIgAEcounts.
Dile Signed --� Signature of Candidate or Tress r
CRD-3500 Certification of Financial Account Information