Finnegan,Colette_2025-WaiverMailing Address Phone
P.O. Box 27255 (919) 814-0700 or
Raleigh, NC 27611-7255 (866) 522-4723
AFFIDAVIT TO
REQUEST A WAIVER OF
CIVIL LATE PENALTIES
PAGE 1 OF 2
• Apolitical committee or referendum committee requesting a waiver of a civil late penalty under G.S. §163-278.34(a)
must complete and file this form with the State Board of Elections. 08 NCAC 21.0206.
• The form must be filed within 60 days of service of the notice of penalty assessment. 08 NCAC 21.0206.
• The State Board may waive a late penalty if it determines there is good cause for the waiver. Please include all relevant
facts or circumstances on this form. You may attach additional pages if necessary.
• An affidavit is a statement given under oath that its contents are true and accurate. By signing this affidavit form, you
swear, under penalty of perjury and other penalties established by North Carolina Law, that the information provided in
this affidavit is true, correct, complete, and of your own personal knowledge.
• Please note, this form will be disclosed to the public as provided in the North Carolina Public Records Act.
• The form may be filed bymail to: NC State Board of Elections, PO Box 27255, Raleigh, NC 27611-7255, or by email to
campaign.reporting@ncsbe.gov. f you choose file by email, an original signed copy of the form must be retained for at
least two years counting from the date of the election to which the late report affects. 08 NCAC 21.0206.
• For more information, please review 08 NCAC 21.0206 or visit the State Board of Election's website at www.ncsbe.gov.
1 1—IIn;AlA nl.nrin
Information
About You
Name
I-,1-1
Address
City State Zip Code
2 G116tVn Pd Ma (h(� being duly sworn, stated:
Sworn Affidavit Name
1.1 am over 18 years of age, of sound mind, and I have personal knowledge of the facts stated herein.
2.1 am a resident of Union CA un -W , NC,
3. 1 am the:
and State of Residence
❑ Authorized Candidate for ❑ Treasurer of
❑ Chair of ❑ Vice -Chair of
_�(Secretary of
E -Mail Address
Telephone Number
2 G116tVn Pd Ma (h(� being duly sworn, stated:
Sworn Affidavit Name
1.1 am over 18 years of age, of sound mind, and I have personal knowledge of the facts stated herein.
2.1 am a resident of Union CA un -W , NC,
3. 1 am the:
and State of Residence
❑ Authorized Candidate for ❑ Treasurer of
❑ Chair of ❑ Vice -Chair of
_�(Secretary of
O
Va
2
Sworn Affidavit
(Continued)
NORTH CAROLINA
STATE BOARD OF ELECTIONS
AFFIDAVIT TO
REQUEST A WAIVER OF
CIVIL LATE PENALTIES
PAGE 2 OF 2
4. The committee was assessed a penalty by the North Carolina State Board of Elections on
12� 23 12024
—� Date of Penalty
❑ First Quarter Report
❑ Second Quarter Report
❑ Third Quarter Report
❑ Fourth Quarter Report
202L
Report Year
0 Mid -Year Semiannual Report
❑ Year -End Semiannual Report
Municipal Report
5. On behalf of the committee, I am formally requesting a waiver of the penalty described in
paragraph 4.
6. Please describe all facts and circumstances you would like the State Board to consider in
reviewing your waiver r quest. Attach add�' tional pa es if nec ssa
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7. The facts and circumstances described in this affidavit are true and accurate to the
best of my
of
State of North Carolina, County of
Sworn to (or affirmed) and subscribed before me,
This 'J r day of 20 (35
S aQturq of Not�1,2aI
Printed Name of Notary Pu licof Notary Pu lic:
Co��e.
My Commission Expires
tj
Date
Notary Stomp or Seal
°O
Sandra L Coble
NOTARY PUBLIC
N0�taY �
Union County
pUBI�° u
`�,
North Carolina
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My Commission Expires
July 4,2029