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Cohn,David_2023-Committee-formsStatement of Organization - Candidate Committee Is this statement: New Q Amended Use this form 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 year. 1. Committee Information a. Name of Committee_ d. ID Number t✓.lA okr, f JAu F . MaBtag Address (laciade Clty, State and Zip Code) e. Date Organized 7 _ r- 4, le- . Committee Website (Optional) Z .1rD t] C E Phone Number ( 2. Candidate Information . Full Name 'art 2`— e. Party Affiliation . Malling Address (include City, State, and Zip Code) f. office Sought +�rnda�� /sa G �� ?g'o•7�'j I�Q�Or . Phone Number d. Emaa ess S. Neat Election Year h. Jurisdiction (/1SGJRG I2 Email co of report notices 3. Treasurer Information 4. Assistant Treasurer Information . Full Name a. Full Name D3�id �otnc- 6Dkei . Mailing Address (include City, State, and Zip Code) b. Mailing Address (include City, , State and Zip Code) ID t; FI r P� �r�i . Pho Number d. Email Addresa c. Phone Number d. Email Address 0 a v/'6/1 ce (X Send report notices by email 0 Yes No ITEniatl co v of, report notices . Custodian of Books Information (Keeper of Records 6. Account Information (incl. CRO -3500) . Full Name a. Financial Insolation Full Name . Malling Address (include City, State, and Zip Code) Phone Number Id. Emaa Address b. Account Code Is. Type t] Email copy of report notices I certify that the Committee is in comphance with all applicable provisions of Article 22A of Chapter 163 of the NC General Statutes and that no funds are commingled with prohibited or other non -disclosed funds. I further certify that this re rt is co`pplete, true and correct. C' -PM r Printed Name of Treasurer Signature of Appomted Treasurer Date I 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 a urer and subject to the penalties in Article 22A of Chapter 163 of the NC General Statutes. �jr�2 ��/� n �I;,d C01� !s Printed Name of Candidate Signature of Candidate Date CRO -2100A NC State Board of Elections November 2019 VOTE © 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: 1 Committee Name: �?utA Treasurer Name: L1 t-0&1 I Treasurer Address: fiC IR F-111:1 r 4!C (include city, state, & zip) Treasurer Phone: %© '/% C% Cheyk 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, 1 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. 1 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 further agree to file all fa a reports required. 7-/ / -/0> Date Signed LSignature CRO -3600 Certification of Threshold PTE NOPTH CAROLINA STATE BOARD OF ELECTIONS I 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: Treasurer Name: Treasurer Address: (include city, state, & zip) Treasurer Phone: -Dex rokA - or Ka�toR- 2�)rtU I I C—akn 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 desienate 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 e Q C�Gt�LtA P1f%o By signing this statement, I authorize agents of the Mte oai3"df Elechi5ns/to ins ect all accounts provided. 7--17 33 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, l authorize agents of the State Board of^Elections to insssect applicable accounts. 001> Date Signed S gnature of Candidate or Treasurer CRO -3500 Certification of Financial Account Information 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: Tctn )OU'A C &n Committee Name: Treasurer Name: If Candidate is own treasurer, designate an agent to cavy out designations: su Committee ID #: T J K'L) Yr- Level F Level Registered: [State] [County] If county, specify: I, v )ecy to Cr- 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) he paid in the following manner as permitted by N.C. Gen. Stat. 163-278.16B(a). Name of Entitv (Select from §163-278.16B(9)) 1. 34er R td!ir- 94i k -h4: 3. 7/se. ).slot Plan for Disbursement (eg. Amount or %) So .9,60 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: �A /1�--�Yr/) Date: 7— f —'Z3 CRO -3900 Candidate Designation of Committee Funds