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Statement 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 reouired fnr each new eleminn venr
1. Committee Information
a. Name of Committee
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d. ID Number '
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b. Mailing Address (include City, State and Zip Code)
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e. Date Organized
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c. Committee NVebsi[e (Optional)
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I. Phone Number
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2 -Candidate Information -
- -
a. Full Name
a -Party Affiliation
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b. Mailing Address (include City, State, and, Zip Code)
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c. Phone Number "
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'd. Email Address " '- _
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g. Next Election Year
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1h. Jurisdiction
❑ Email copy of report notices
3. Treasurer Information
4. Assistant Treasurer Information
a. Full Name - - -
a. Full Name
b. Mailing Address (include City, State, and Zip Code)
b. Mailing Address (include City, State and Zip Code)
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210, COTMIA Mill e -T ar 5 NG•
c. Phone Number
di Email Address
c. Phone Number
d. Email Address
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1Send
report notices by email ❑ Yes ❑ No
L1 Email copy of report notices
5. Custodian of Books Information (Keeper of Records
6. Account Information (incl CRO -3500) ---
a. Full Name - - -
a. Financial Institution Full Name
h. Mailing Address (include City, State, and Zip Code)
c. Phone Number Id.
Email Address
b. Account Code
c. Type.
❑ 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 wi rohibited or other non -disclosed funds. I further certify that
this report is complete, true and correct.
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rimed 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 t er and subject to the penalties in Article 22A of Chapter
163 of the NC General Statutes.
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Signature of Can tdate Date
CR0-2106A NC State Board of Elections November 2019
NORTH CAROLINA
STATE BOARD OF ELECTIONS
I Certification of Threshold I
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: I.04 CMAD& ) Sl/il:,utNCS VO4 COwNu l t7 Z r
Treasurer Name:
Treasurer Address: 2401 Conk M'f% Gil
(include city, state, & zip) K�raf&k, /iZ e-. ?,is I
Treasurer Phone: '7oq-LVM•13?3�o
C ec ne:
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 retrain 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 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. I further agree to file all future reports required.
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Date Signed gnature
CRO -3600 Certification of Threshold