Deatherage,Wayne_2025-SOGStatement 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 acconmanied by form CRO -3500. An amended fnnn is rennired fur each rea PT.,•ti,.., ..e�.
1. Committee Information
a. Name of Committee
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d. ID Number -
b. Mailing/ ddmress (include City, State and Z' Li(Code)
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e. Date Organized
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c. Committee Website (Option )
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f. Phone Number
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2. Candidate Informatioil
_
a. Full Name -
e. Party Affiliation -
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b. Mailing Ad ress (Incl de �Cii r, State, and ZI Code)
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f. Office SouAt
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c. Phone INiumber7
d. Email Address
. gNext Election Year
h. Jurisdiction
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❑ Email coov of re ort notices
3. Treasurerlaformation 7
4. Assistant'.
a. Full Name -
a. Full Name -
b. Mailing Address (inc de Ci�� State, and Codej
b. Mailing Address (include. City, State and Zip Code)
c. Phone Number
d. Email Address
c. Phone Number
d. Email Address
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Send report notices by ail- ❑ Yes ❑ No
U Email copy of report notices
5.' Custodian. of Books Inf rmatiom (Keeper of Records
6. Account Information (inct CRO -3500)
a. Full Name - - -
a. Financial Institution Full Name
b. Mailing Address (include City, State, and Zip Code)
-
c: Phone Number -
d. 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 with prohibited or other non -disclosed funds. I further certify that
this report is complete, true and correct.
Prmted,NllXi of Treasurer Si azure of Appointed Treasurer Date
I certify that the information above is correct, and 1, as t e 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.
eaewfih e
Print Name of Candidate ' nature of Candidate Date
CRO -2100A NC State Br of Elections November 2019
PTE NOPTH CAROLINA
STATE BOARD OF ELECTIONS
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 ounce,
municipal office, local school board office, soil & water conservation district board of supervisors, or
sanitary district board.
This Certification is tiled at the Board of Elections office where the committee's campaign reports
are filed.
FILED BY:
Committee Name:
Treasurer Name:
Treasurer Address:
(include city, state, & zip)
Treasurer Phone:
Check One:
1 certify that this committee intends to neither receive nor expend more than $1,000 during the current
el ttion 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 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.
7�
Date
Signed Signature
CRO -3600 Certification o/'Threshold
VOTE
rT1T�
NORTH CAROLINA
STATE BOARD OF ELECTIONS
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:
Treasurer Name:
Treasurer Address:
(include city, state, & zip)
Treasurer Phone:
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 (or candidate) must designate below an account code (anv 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 cornmingle those funds with any other moneys.
Type of account Financial Institution Address Account Number Account Code
By signing this statement. 1 authorize agents of the State Board of Elections to inspect all accounts provided.
Date Signed Signature of Candidate or Treasurer
For Candidate Committees Only �
In lieu of providing account information, I certify that this committee will not rais 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, 1 authorize agents of the State Board of ections to ins ect appli le accounts.
Date Signed Signature of Candidate or Treasu
CRO -3500 Certification of Financial Account Information
NORTH CAROLINA
STATE BOARD OF ELECTIONS
Additional account numbers:
Tvpe of Account Financial Institution Address Account Number Account Code
Date Signed Signature of Candidate or Treasurer
CRO-3500 Certificulion of Financial Account Information