Staton,Ernestine_2019-SO-AmendmentStatement of Organization - Candidate Committee
Use this form to create a new or update an existing candidate committee.
This form must be accompanied bv fornis CRO -3100 and CRO -3500 (schen amendine
andment
Yes ❑ No
only re -submit if applicable).
1. Committee Information
. Full Name
c. ID Number
fl
. hailing Address (Include State and Zip Code)
d. Date Organized
^City,
i `cJ ih.J�lo ti� �Bln3
e. Phone Number
� 3&Z-- CD e'r'r
2. Candidate Information []Candidate's Primary Committee
.r. Full Name
Y- Y—vi,
e. Candidate ID Number
if. Party Affiliation
j(Indicate Non-partisan if applicable
b. Mailing Address (include City, State, and Zip Code)
g. Office Sought
(�4JS V\J.\kt kK—AA
. Phone Number
d. Email Address
It. Next Election Year
i Jurisdiction
Dyi 2YI)
,aOh
❑Email cop) of notices
. Treasurer Information
4. Custodian of Books Information
. Full Name
r nr\u—
a. Full Name
�P_ v �-: ne 5 � n
. Mailing Address(include City, State,and Zip Code)
b. Mating Address (include Ci(y, State, and Zip Code)
P'e5,.6 rN
N&G', V% Ij \C A\/ <,
. Phone Number
Id. Enlail Address
c. Phone Number
d. Email Address
7-
1 prefer to receive notices by email 1'es ❑ No
U Email copy of notices
5. Assistant Treasurer Information
Add
6. Account Information Pmol. CRO -3500) ❑ Add
a. Financial Institution Full Name Remove
a . Full Name
❑ Remove
b. Mailing Address (include City, State, and Zip Code)
b. Purpose
. Phone Number
d. Email Address
c. Account Code
d. TY pe
Email copy of notices
CERTIFICATION
1 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.
E�'n't-ALt,e- � � , Y \5 i9
Printed Name of Signer Signature of Appointed Treasurer Date
CRO -2100A NC State Board of Elections July 2011