Belk,Kim_2025-WaiverNORTH CAR
STATE BOARD ,OF E
Mailing Address Phone
P.O. Box 27255 (919) 814-0700 or
Raleigh, NC 27611-7255 (866)522-4723
I• A AFFIDAVITTO
REQUEST A WAIVER OF
CIVIL LATE PENALTIES
ECT;IONS PAGE 1oF2
• Apolitical committee or referendum committee requesting a waiver of a civil late penalty under G.S. §163-278.34(a)
must complete and file this form with the State Board of Elections. 08 NCAC 21.0206.
• The form must be filed within 60 days of service of the notice of penalty assessment. 08 NCAC 21.0206.
• The State Board may waive a late penalty if it determines there is good cause for the waiver. Please include all relevant
facts or circumstances on this form. You may attach additional pages if necessary.
• . An affidavit is a statement given under oath that its contents are true and accurate. By signing this affidavit form, you
swear, under penalty of perjury and other penalties established by North Carolina Law, that the information provided in
this affidavit is true, correct, complete, and of your own personal knowledge.
• Please note, this form will be disclosed to the public as provided in the North Carolina Public Records Act.
• The form maybe filed by mail to: NC State Board of Elections, PO Box 27255, Raleigh, NC 27611-7255, or by email to
campaign.reporting@ncsbe.gov. f you choose file by email, an original signed copy of the form must be retained for at
least two years counting from the date of the election to which the late report affects. 08 NCAC 21.0206.
• For more information, please review 08 NCAC 21.0206 or visit the State Board of Election's website at www.'ncsbe.gov.
1 Kim Belk
Information Name
About You 15812 Idlewild Rd.
Address
Indian Trail NC 28079
City State Zip Code
belkroofing1760@gmail.com 704-339-7153
E -Mail Address
2 Kim Belk
Sworn Affidavit
Name
Telephone Number
being duly sworn, stated:
1. 1 am over 18 years of age, of sound mind, and I have personal knowledge of the facts stated herein.
2.1 am a resident of Union County, NC
County and State of Residence
3. l am the:❑ Authorized Candidate for p Treasurer of
❑ Chair of ❑ Vice -Chair of
❑ Secretary of
Kim Belk For Hemby Bridge Alderman
Name of Committee
"VOIkE) NORTN CAROLINA
2
Sworn Affidavit
(Continued)
3
Jurat
STATE BOARD OF ELECTIONS
AFFIDAVIT TO
REQUEST A WAIVER OF
CIVIL LATE PENALTIES
PAGE 2 OF 2
4. The committee was assessed a penalty by the North Carolina State Board of Elections on
12/23/2024
Date of Penalty
❑ First Quarter Report
❑ Second Quarter Report
❑ Third Quarter Report
❑ Fourth Quarter Report
2024
Report Year
❑✓ Mid -Year Semiannual Report
❑ Year -End Semiannual Report
-1
Municipal Report
5. On behalf of the committee, I am formally requesting a waiver of the penalty described in
paragraph 4.
6. Please describe all facts and circumstances you would like the State Board to consider in
reviewing your waiver request. Attach additional pages if necessary.
N 0 VV SAI,— 6 -ZV4 .
7. The facts and circumstances described in this affidavit are true and accurate to the
best of my knowledge.
X v
Signature of Affiant
State of North Carolina, County ofy/ l0 h
Sworn to (or affirmed) and subscribed before me,
This k2" t
day of 1—tbruwT 20
Z15 -
Signature of Notary Public:
c'4�'�_ C •4yae.a&V, o
Printed Name of Notary Public:
1 JOY1na lam• /��'Gt�liol�s
My Commission Expires 06 1207-9
Date
Notary Stamp or Seal
Uonna C. Meadows
Notary Public
Union County, N.C.