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Palacios,Maria_2022-4th-qtrDisclosure Report Cover Amendment l] Yes ® No Use this form for general report and committee information, must be signed and submitted along with other detailed forms. Do not use this form to update information. 1. Committee Information a. Full Name c. ID Number COMMITTEE TO ELECT MARIA PALACIOS XXX-OJMK89-X-XX b. Mailing Address (include City, State and Zip Code) d. Date Fled 3903 GARRISON CT 01/09/2023 MONROE, NC 28110 e. Phone Number (704)207-5519 2. Report Year 3. Period Start Date (mm/dd/yy) 4. Period End Date (mm/dd/yy) 5. Treasurer Full Name 2022 10/23/2022 12/31/2022 CRISTAL ROBINSON 6. T3pe of Committee (Check One) 9. Type of Re 1pmort (check onlX one tye ofre ort from one cate o ) ® Candidate Campaign ❑ Party Municipal State/County Referendum ❑ Joint Fundraiser ❑ PAC ❑ Organizational ❑ Organizational ❑ Organizational ❑ Referendum ❑ Legal Expense Fund ❑ ❑ ❑ Thirty-five day Pre-primary Pre-election Quarterly ❑ First ❑ Second ❑ Pre -referendum ❑ Final ❑ Supplemental Final 7. Type of Fund (ifapplicable, check one) ❑ 'Booster Fund" ❑ Building Fund ❑ Pre -runoff Third ❑ Annual ❑ Presidential Election Year Candidates Fund Semi-annual Fourth ❑ Special ❑ NC Public Campaign Financing Fund ❑ Mid Year Semi-annual ❑ Year End ❑ Mid Year 10. Special Re rt Name ❑ Other: ❑ ❑ Final Special ❑ Year End [3 Final ❑ Special 8. Number of Fundraisers this Re rt - 0 3. Account Information 3. Account Information a. Financial Institution Full Name a. Financial Institution Full Name FIRST CITIZENS BANK b. Purpose c. Account Code b. Purpose c. Account Code COMMITTEE B01 d. Period Begin Balance d. Period Begin Balance $ $ CERTOICATION I certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 22B & 22D -22M 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 and that I have been trained by the NC State Board �t S . 4. i ,' 6'.✓ 01/09/2023 Printed Name of Signer �u&.of"Appointed Treasurer Date FOR OFFICE USE ONLY Date Received: I Employe Delivery Method ❑ Normal Mail Date Postmarked:1 ❑ Registered Mail 044and Delivered Date Scanned: EmployeeJA 11 2023 ❑ Electronically Filed Date Data Entered:[3Signer has not received Emp[�131®a:CO Rnar i nf Fly, : mandatory training Please Note: This formcannot be used to amend committee information such as the committee address, treasurer, assistant treasurer, custodian of books information, or account information. You must amend the Statement of Organization CRO -2100A -E to make connmittee changes. CRO -1000 NC State Board of Elections December 2007 Amendment Detailed Summary ❑ Yes ® No 1 ice this fnrrn to enmmari7e all diaclnanre. renortinu forma and to total monetary information 1. Committee Full Name and Fund if a icable 2. TVpe of Re rt 13. ID Number COMMITTEE TO ELECT MARIA PALACIOS 2022 Fourth Quarter XXX-OJMK89-X-XX Start of Election Cycle: January 1, 2021 Total this Reporting Period Total this Flection Cycle 4) Cash on Hand at Start $ 336.48 $ 0.00 RECEIPTS 5) Aggregated Contributions from individuals 6) Contributions from Individuals 7) Contributions from Political Party Committees 8) Contributions from Other Political Committees 9) Loan Proceeds 0) Refunds/Reimbursements to the Committee 1) Other Receipt Sources 11 a) Interest on Bank Accounts 11 b) Contributions from Not -For -Profit Organizations Ile) Outside Sources of Income 11d) Legal Expense Fund- Other Sources 11e) Exempt Purchase Price Sales (CRO -1205) (CRO -1210) (CRO -1220) (CRO -1230) (CRO -1410) (CRO -1240) (CRO -1250) (CRO -1250) (CRO -1250) (CRO -1270) (CRO -1265) $ 3.00 $ 555.37 $ 10.70 $ 2,658.52 $ 200.00 $ 300.00 $ 0.00 $ 0.00 $ 0.00 $ 1,257.18 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 2) TOTAL RECEPTS (Add lines 5, 6, 7, 8, 9,10,1 la,l lb,llc,l ld and Ile) $ 213.70 $ 4,771.07 EXPENDITURES 3) Disbursements 13a) Operating Expenditures 13b) Contributions to Candidates/Political Committees 13c) Coordinated Party Expenditures 4) Aggregated Non -Media Expenditures 5) Loan Repayments 6) Refunds/Reimbursements from the Committee 7) In-lUnd Contributions (CRO -1310) (CRO -1310) (CRO -1310) (CRO -1315) (CRO -1420) (CRO -1320) (CRO -1510) _ r , $ 0.00 $ 2,050.32 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 1.20 $ 711.77 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 1,460.00 8) TOTAL EXPENDTITRFS (Add lines 13a, 13b, 13c, 14, 15, 16 and 17) $ 1.20 $ 4,222.09 9) Cash on Hand at End (Add lines 4 and 12 together, then subtract line 18) $ 548.98 $ 548.98 ADDITIONAL INFORMATION 0) Non -Monetary Gifts Given to Other Committees (CRO -1330) 1) Outstanding Loans (incl. ones from other campaigns) (CRD -1430) 2) Debts and Obligations owed by the Committee (CRO -1610) 13) Debts and Obligations owed to the Committee (CRO -1620) 4) Account Transfers Within the Committee (CRO -1720) fo) 5) Administrative Support RECE 6) Forgiven Loans e{ e{ �Cwo_?2 7) 48 -Hour Notice Reports Sum jb..ChO2�) $ 0.00 $ 1,257.18 $ 0.00 $ 0.00 $ 0.00 ,,1 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 8) Contributions to be Refunded R C O- �2 5 },, ,$_ 0.00 $ 0.00 CRO -1100 Nl," J'rate tsoara or tiecuons r UgUSL <VVo Amendment Aggregated Contributions from Individuals Page 1 of I ❑ Yes ® No Optional form used to report NC Contributions From Individuals of $50 or less 1. Committee Full Name and Fund if a icable 2. ID Number COMMITTEE TO ELECT MARIA PALACIOS XXX-OJMK89-X-XX 3. Contributor Information a. Amend b. Account Code c. Form of Payment d. In -Kind Description e. Date (mm/dd/yyyy) if. Amount Add__ ❑ Remove B01 Credit Card ..- 10/28/2022 - --- - - - -- $ 3.00 4. Total only this Page , $ $3.00 5. Total of ALL CRO -1205 Pages (This line must be on line 5 of Detailed Summary Page CRO -1100) $ $3.00 CRO -1205 NC State Board of Elections April 2007 RECEIVED JAN 11 2023 Union Co. Board of Elections Contributions from Individuals Amendment Pg 1 of 1 ❑ Yes ® No Use this form to report individual contributions over $50 or contributions under $50 if form CRO 1205 is not used 1. Committee lull Name and Fund if a icable 2. ID Number COMMITTEE TO ELECT MARIA PALACIOS XXX-OJMK89-X-XX 3. Contributor Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession d. Comments Software Engineer DANIEL HANNUM 4116 Hoffineister Drive WAXHAW, NC 28173 c. Dnployer's Name/Specific Field CREDIT KARMA e. Flection Sum to Date $ 96.30 f. Prior g. Account Code h. Form of Payment i. to-IGnd Description j. Date (mm/dd/yyyy) k. Amount ❑ 1301 Credit Card 11/06/2022 $ 10.70 ❑ $ 4. Total only this Page $ 10.70 5. Total of ALL CRO -1210 Pages (This line must be online 6 ojDetailed Summary Page CRD -1100) S$ 10.70 CRO -1210 NC State Board of Elections Apni 200i %n� A I Amendment Contributions from Political Party Committees Pg I of I []Yes ® No Use this form to report contributions from a political party 1. Committee Full Name and Fund if a cable 2. ID Number COMMITTEE TO ELECT MARIA PALACIOS XXX-OJMK89-X-XX 3. Contributor Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Comments UNION COUNTY DEMOCRATIC WOMEN 7905 Tottenham Ct WAXHAW, NC 28173 c. Flection Sum to Date $ 200.00 d. Account Code e. Form of Payment f. In -Kind Description g. Date (mm/dd/yyyy) h. Amount 1301 Check 11/07/2022 $ 200.00 -F 4. Total only this Page $ 200.00 5. Total of ALL CRO -1220 Pages (This line must be online 7 of Detailed Summary Page CRO -1100) $ i 200.00 CRO -1220 NC State Board of Elections April 2007 JAN 11 2023 Union Co. Board of Elections Ame ndme nt Aggregated Non -Media Expenditures Page I of I ❑ Yes ® No Ontional form used to report NC Non -Media Expenditures of $50 or less. 1. Committee Full Name (and Fundif applicable) COMMITTEE TO ELECT MARIA PALACIOS 2. ID Number XXX-OJMK89-X-XX 3. Payee Information a. Amend b. Account Code c. Form of Payment Purpose Code e. Date (mm/dd/yyyy) f. Amount g. Required Remarks Add ❑ Remove Bol Draft Id. K 10/31/2022 $ 1.20 BANK FEE 4. Total only this Page $ 1.20 5. Total of ALL CRO -1315 Pages (This line must be on line 14 of Detailed Summary Page CRO -1100) $ 1.20 6. Purpose Codes List detailed expenditure code in d above B* - Printing C* - Fundraising D - To Another Candidate E - Salaries F* - Equipment G - Political Party H* - Holding Public Office Expenses I - Postage J - Penalties K* -Office Expenses Q* - Donations to Legal Expense Fund O* - Other * Codes require detailed explanation in required remarks field CRU -1315 tvt. xace rsoara of niccuoas Outstanding Loans Amendment Pg 1 of 2 ❑ Yes ® No Use this form to report any outstanding loans received during a previous reporting period and until the loan is paid in full. 1. Committee Fall Name tand Fund if a icable z. ID Number COMMITTEE TO ELECT MARIA PALACIOS XXX-OJMK89-X-XX 3. Lender Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession d. Comments MANAGER MARIA PALACIOS 3903 GARRISON CT MONROE, NC 28110c. (704) 207-5519 e. Start Date (mm/dd/yyyy) . i Employer's Name/Specific Field 12/28/2021 - --_. AUTO TECH f. End Date (mm/dd/yyyy) g. Rate h. Security Pledged i. Original Loan Amount j. Remaining Loan Balance % $ 60.00 $ 60.00 k. Full Name of Lending Institution 1. Loan Number 3. Lender Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession d. Comments MANAGER MARIA PALACIOS 3903 GARRISON CT MONROE, NC 28110 (704) 207-5519 e. Start Date (mm/dd/,yyyy) c. Employer's Name/Specific Field 12/28/2021 AUTO TECH f. End Date (mm/dd/yyyy) g. Rate h. Security Pledged i. Original Loan Amount j. Remaining Loan Balance % $ 150.00 $ 150.00 k. "ll Name of Lending Institution 1. Loan Number 3. Lender Information ❑ Add ❑ Remove a. FL11 Name, Mailing Address & Phone (include city, (' ty, state, & zip) b. Job Ti tie /Profession d. Comments MANAGER --- — MARIA PALACIOS 3903 GARRISON CT MONROE, NC 28110 (704) 207-5519 e. Start Date (mm/dd/yyyy) e c. Employer's Name/Specific Field 12/28/2021 _ _ -_ AUTO TECH f. End Date (mm/dd/yyyy) g. Rate h. Security Pledged i. Original Loan Amount j. Remaining Loan Balance % $ 276.00 $ 276.00 k. Full Name of Lending Institution I. Loan Number �L 4. Total only this Page --w: $ 486.00 5. Total of ALL CRO -1430 Pages (This line must be online 21 ofDetuiled Summary Page CRO -1100) UniOn CO. Bo -rd n, f r! tinn $ 1,257.18 CRO -1430 NC State Board of Elections December 2007 Outstanding Loans Amendment Pg 2 of 2 ❑ Yes ® No Use this form to report any outstanding loans received during a previous reporting period and until the loan is paid in full. 1. Committee Fall Name and Fund if a icable z. ID No mber COMMITTEE TO ELECT MARIA PALACIOS XXX-OJMK89-X-XX 3. Lender Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) MARIA PALACIOS 3903 GARRISON CT MONROE, NC 28110 (704) 207-5519 b. Job Title/Profession MANAGER c. Employer's Name/Specific Feld AUTO TECH d. Comments e. start Date (mm/ad/yyyy) 10/10/2022 f. End Date (mm/dd/yyyy) g. Rate h. Security Pledged i. Original Loan Amount j. Remaining Loan Balance LOAN -TEACHER SLATE CARDS- UPRINTING $ 771.18 $ 771.18 k. Full Name of Lending Institution 1. Loan Number 4. Total only this Page $ 771.18 5. Total of ALL CRO -1430 Pages (This line must be on line 21 of Detailed Summary Page CRO -1100) $ 1,257.18 CRO -1430 NC slate Board of Elections wv i