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statement of Organization - Candidate Committee
Use this form to create a new or update an existing candidate committee.
Tjiisjonp must be accompanied by form CRO-3500. An amended form is required for each new election year.
Is tjHSstatement;
Wew [2] Amended
1. Committee Information
a. Name of Committee
b. Maiiiag Address (include City, State and Zip Code)
c. Committee Website (Optional)
2. Candidate Information
d. ID Number
e. Date Organized
f. Phone Number
a. Full Name
b. Mailing Address (include City, State, and Zip Code)
AA , Nc C.ic. Phone Number . Email y^ddrcss
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□ Email copy of report notices
3. Treasurer Information
a. Fuii Name
b. Mailing Address (include City, State, and Zip Code)(^Cl Vv-r-C^I^.C^ CU,
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c. Phone Number
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'd. Emah Address
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5. Custodian of Books Information (Keeper of Records)
a. Full Name
. Mailing Ad
{-exL^ry ^ /b. Mailing Address (include City, State, and Zip Code)
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c. Phone Number d. Email Addressof}- 727<H Ir, 'c/^?pHaSdiiil copy of report notices '•z
e. Party Affiliation
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f. Office Sought
g. Next Election Year
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h. Jurisdiction
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4. Assistant Treasurer Information
a. Full Name
t>fprr\cin s /c.b. Mailing Address (include City, State and Zip Code)
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c. PhonejNum
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d..Emaii Address
fa^mail copy of report notices"
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. Account Information (ind CRO-i500)
a. Financial Institution Full Name
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b. Account Code c. Type(AsUjjjjirLa^
ify that the Committee is in compliance with all applicable provisions of Article 22A of Chapter 163 of the NO'eral Statutes and that no funds are commingled with prohibited or other non-disclosed funds. I further certify thatyj^I^^ort is complete, true and correct. \ ^
. Printed Name ofTreasurer ( t /1 Signaldre qfAppointed Treasurec T T / vpate_ /Yi, X>^-)mhkiI certify that the information above is correct, and I, as the candidate, appoint said treasury 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 NO General Statutes._^ r» 0loj oi uic iNu uenerai oianues. a ^
^ ^^ ^ Imprinted Name of Candidate f Si^ature of Candidate T~Date
NoW NC State Board of Elections
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November 2019
UNION COUNTY ^
BOARD OFELECTIONB