Gay,Dennis_2021-CommitteeStatement 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 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
Committee To Elect Dennis Ga
b. Mailing Address (include City, State and Zip Code)
e. Date Organized
5106 Old Charlotte Highway, Monroe, NC 28110
15 July 2021
c. Committee Website (Optional)
I. Phone Number
704 345-8616
2. C linfilidate Information
. Full Name
e. Party Affiliation
William Dennis Gay
Nonpartisan
. Mailing Address (include City, State, and Zip Code)
f. Ofnce Sought
4705 Pioneer Lane
Indian Trail, NC 28078
Council Member
c. Phone Number
d. Email Address
g. Next Election Year
h. Jurisdiction
Town of Indian Trail
704 345-8616
stainlessb aol.com
2021
17 Email copy of report notices
3. Treasurer Information
4. Assistant 'reasurer Information
a. Full Name
a. Full Name
Randall Haron Ga
b. Mailing Address (include City, State, and Zip Cade)
b. Mailing Address (include City, State and Zip Code)
5106 Old Charlotte Highway
Monroe, NC 28110
c. Phone Number
d. Email Address
c. Phone Number
d, Email Address
252 723-1525
r 2009 liye.com
Send re ort notices b email Yes No
Email co of report notices
5. Custodian bt l3oohs information (Keeper o Records
6. Account Information (hitt. CRO -950d)
a. Full Name
a. Financial Institution Full Name
Randall Haron Gay
American Bank
. Mailing Address (include City, State, and Zip Code)
FAIGN-FINANCE—
5106 Old Charlotte Highway
Monroe, NC 28110
1111 9 1 2021
:Phone Number
d. Email Address
b. Account Code
c. Type
252 723-1525
rg2009@live.com
01
RECEIVED
Chec in
0 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 prohibited or other non -disclosed funds. I further certify that
this report is complete, true and correct.
Randall Haron Gay
Printed Name of Treasurer
Signature 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 appointed treasurer
and subject to the penalties in Article 22A of Chapter
163 of the NC General Statutes.
William Dennis Gay -4
A-47 % Z°2
Printed Name of Candidate
Signatu of Candidal Date
CRO -2100A NC State Board of Elections November 2019
aIGN
�"KANORTH CAROLINA
TE BOARD OF ELECTIONS
JUL 21 2021
RECEIVED
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:
Committee To Elect Dennis Gay
Treasurer Name:
Randall Haron Gay
Treasurer Address:
5106 Old Charlotte Highway
(include city, state, & zip)
Monroe, NC 28110
Treasurer Phone:
(252) 723-1525
Check One:
x 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 ata 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 further agree to file all future reports required.
Date Signed Signature
CRO -3600 Certification of Threshold
voTE
NOPTH CAPOLINA
ST1�TE BOARD OF ELECTIONS
ION COUNT
CAMPAIGN FINANCE
JUL 21 2021
RECEIVED Con idential
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: Committee To Elect Dennis Gay
Treasurer Name: Randall Huron Gay
Treasures' Address: 5106 Old Charlotte Highway
(include city, state, & zip) Monroe, NC 28110
Treasurer Phone: (252) 723-1525
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 for 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
Checking American Bank 312 N. Charlotte Ave. Monroe,NC 01
By signing this statement, I authorize agents of the State Board of Elections to mspe t all accounts provided.
2
Date Signed Signature of Candidate or Trea er
For Candidate Comanittees 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 accounts.
Date Signed Signature of Candidate or Treasurer
CRO -3500 Certification of Financial Account Information