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Anthony, Surluta_2021-01-Stmt-of-OrgStatement of Organization - Candidate Committee Is th)'s 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 required for each new election year. 1. Committee Information a. Name of Committee_ d. ID Number nq b. Mailing Address include City, State and Zip Code e. Date Organized v1 ,r-tnu� 11Y- l C. Committee Website (optionso f. Phone Number -70 898 s/� 2. Candidate Information a. Full Name e. Part, Affiliation _ Lla,., It. Mailing Address (include City, State, and Zip Code) I. Office Sought C6LA, W.tI c. Phone Number d. mail Address g. Next EI tion Year It. Jurisdiction FL L 1 ^y C " [3 Emailtices t 3. TreasurIoort ' CAsisantTreasurerInf a. I ull Name a. Full Name rM� n• b. Mailing Addre (include City, State, and Zip Code) b. Mailing Address (include City, State and Zip Code) 5a8 E. 7,t1leyran4 A-ve.. c. Phone Number Id. Email Address c. Phone Number d. Email Address Off -2f2-37 3 P�+►�ilymc9ir�oitl m ecen�I Send report notices by email ❑ yes ❑ NW Itmail copy of report notices 5. Custodian of Books Information (Keeper of Records 6. Account Information (incl. CRO - a. Full Name a. Financial Institution Ful CA In / r nA G "l n r 5 b. Mailing Addres (include ('iw, Statc, and Zip Code) 603 P - Tillcy `anal Ave RECEIVED . Phone Number I d. Email Address b. Account Code 1c. Type Y-4112 - Z r M i4ni ❑ Email copy of report notices Loyly 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. r11, ;/ M�� Af--rs — Printed Panic of Treasurerignature of ointed Treasurer Date I certify that the information above is correct, and I, as the candid point 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. Q r l uf� B. h f itiah c /J• / 2./ Printed Name of Candidate Signature of Candidate Date CRO -2100A NC State Board of Elections November 2019 VOTE © NORTH CARO„A STATE BOARD OF ELS ANITONA JUL 2 3 2021 Con Idendal BFGEIVED 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. 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 (any 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 commingle those funds with any other moneys. Type of account Financial Institution Address 0—v,�eC i Not {—. �c Account Number Account Code By signing this statement, I authorize agents of the State Board f Elections to inspect all ac us v' Wed. Date Signed Signature of Candidate or Treasurer For Candidate Committees Only In lieu of providing account information, I certify that this committee will not raise any money nor spend any money except that which is the candidate's personal funds. I furthermore understand that an audit or investigation could wan -ant the probe of any personal bank account that is being used for campaign expenditures. By signing this statement, I authorize agents of the State Board o coons t sped ap tic ble counts. - /— / [in - Date Signed Si i of Candidate or Treasurer CRO -3500 Certification of Financial Account Information NORTH CAROLINA M13 STATE BOARD OF ELECTIONS g Candidate Designation of Committee Funds This form is used by candidate committees only and allows the candidate to designate in the event of their death, how the committee's funds are to be disbursed using the eight allowable methods outlined in 163-278.16B(a). This Designation is filed at the Board of Elections office where the committee's campaign reports are filed. Candidate Name: S(y�l cc !� • A n +(,o n Committee Name: v 4v. Gv� 1 7(7! G/Cc 1( Sur)a]'7� t�, AP- Treasurer Name: 0 If Candidate is own treasurer, designate an agent to carry out designations: UNION COUNTY CAMPA Committee ID #: JUL 2 3 2021 Level Registered: [State] [County] If county, specify: I, S u✓ ju jz An46 AV hereby direct that in the event of my death or incapacity all (Name of Candidate) funds remaining in my Campaign Committee account(s) (after payment of permitted outstanding debts or reasonable expenses for winding up the Committee or closing office) be paid in the following manner as permitted by N.C. Gen. Stat. 163-278.16B(a). Name of Entity (sdeclfmm §163-278.166(a)) I. ,�Crw an / /n 6b 2. Mn1&0, At l I"ahim, JNeA?4- 3. Plan for Disbursement (eg. Amount or %) Sb 5 b t-') Z) By signing this form, I certify that the foregoing entities are eligible beneficiaries under N.C. Gen. Statute 163-278.16B(a). A copy of this form should be maintained with the Committee records. n Signature of Candidate: Date: -7 ! 7 CRO -3900 Candidate Designation of Committee Funds