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Felts,Chelsey_2023-Committee-formsStatement of Organization - Candidate Committee Is this statement: New' ❑ Amended Use this form to create a new or update an existing candidate committee. This form must he accompanied by form C110-3500_ An amended form is required for each new alection year. Information mittee d. m Number I 7N�o Mulling (incl de City, Sfate and Zip Cade) e. Date Organized oc bsite (Optional) E Phone Number . Candidate Information - - - -"- a. full Same e. Parer k1ilkawn r e 1 S `` l` L t/i . Mailing Address (include City, State, and Zip Code) C Office Sought Ana CA G .1 e ul-A V1 . Phone Number d. Email Address g. Next Eiectton Year It. Jurisdiction P Ise ❑ Email copy of report notices . Treasurer Information 4. Assistant Treasurer Information . Full Name a. Fail Name . Milling Addlrens (biducle City, State, and Zip Code) Is. Mailing Address (include City, State and Zip Code) S t5 f GkIrA nCxc2w5 . Phoue Number Id.11imallAdeirm c. Phone Number d. Email Address � a 44 l Send re ort notices b email Yes No Email co of report notices 5. Custo inn of Books Information (Keeper o Records' 6. Account formation (fncL CRO -35001 ' "- . Full Name a. Financial Institution Full Name C- S . Matting Address (i cls a City, State, and Zip Code) Pborte Number d. Email Address Is. Account Code — - - c. yype IttOR�J. dlGrtti CU011S ❑ Email copy of report notices I 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 prohibits other non -disclosed funds. I further certify that this report is complete, true and correct. Printed NaAe of Treasurer (!91ne of Appointed Treasurer Date I certify that the information above is correct, and I, as the candidate, appoint said treasurer to personally fulfill the duties and responsibilities imposed upon the appo ,tr asurern subject to the penalties in Article 22A of Chapter 163 of the NC General Sta Ugja) Printed N of Candidate Signature of Candidate Date CRO -2100A NC State Board of Elections November 2019 PTH CAR ELECTIO 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, & zip) Treasurer Phone: Check, : 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 requited 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. Ill r a to file all future reports required. ri �� Date Signed RECEIVED Signam 'U! 2 G 2023 Union Co. Board of Eleclions CRO -3600 Cenifrcation of Threshold v© NORTH CAROLINA UMJ 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: 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. 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 dddre.. A.. ... N.....Ae� By signing this statement, I authorize agqte a� t q State Board of Elections to inspect all accounts provided. �'4i d Of El gonS Date Signed Signature of Candidate or Tre wa !Dr Candidate Committees Only In heu 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 campai penditures. By signing this statement, I authorize agents of the State BoCM-0 to et applicable accounts. —1 �c� —�Dale Signed i tura of Candidate or Treasurer CRO -3500 Certification of Financial Account Information IRE-CE1VFD_+ LP 2G%f By signing this statement, I authorize agqte a� t q State Board of Elections to inspect all accounts provided. �'4i d Of El gonS Date Signed Signature of Candidate or Tre wa !Dr Candidate Committees Only In heu 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 campai penditures. By signing this statement, I authorize agents of the State BoCM-0 to et applicable accounts. —1 �c� —�Dale Signed i tura of Candidate or Treasurer CRO -3500 Certification of Financial Account Information