Belk,Kim_2019-CommitteeAmendment
Statement of Organization - Candidate Committee ❑ Yes ❑ No
Use this form to create a new or update an existing candidate committee.
This form must be accompanied by forms CRO -3100 and CRO -3500 (when amending. only re -submit if anolicable).
1. Committee Information
. Full Name
c. m Number
tllf4l' k4 r
as
b. iaog Address (include City, State and Zip Code)
d. Date Organized
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e. Phone Number
? C andidate Information ❑ Candidate's Primary Committee
a. Toll Name
e. Candidate III Number
_,Party Affiliation
(—(halicate
Non-partisan if applicable
. Mailing Address (inc de City, Sta and Zip Code)
g, office Sought
A JXz too
. Phone Number
d. EmailfAddress
h. Next Election r
i. Jurisdiction
L (31
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❑Email copy of notices
. Treasurer Information
4. Custodian of Books Information
. Full Name
a. Full Name
L
ailing Address include Vty, State, and Zip Code)
b. Mailing Address (include City, State, and Zip Code)
d T-4
. Phone Number d. Ema1i'Address
c. Phone Numberd.
Email Address
refer to receive notices by email Yes Lj No
=Email copy of notices
5. Assistant Treasurer Information
Add
E3 Remove
6. Account Information (incl2-3500)
2
Add
❑Remove
. Full Name
a. Financial Institution Full Name
.Mailing Address (include City, State, and Zip Code)
b. Purpose I'''](�
1 ntt C�Mo
. Phone Number
d. Email Address
c. Account Code
d. Type
Union Co. Elec
Email co of notices
CERTIFICATION
I certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 22B & 22D -22M 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. p �� �J
M_ �+?�.��— L�*-rc.K_. a% —I/ yr l l
Printed Name of Signer Signature of Appointed Treasurer Date
CRO -2100A NC State Board of Elections July 2011
�D
9
ions
NORTH 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 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: Ktv,-7 4eAk%- 6}2q,n„_ j f; dC>✓ /l[dPiyYICtG„
Treasurer Name: :l i rw Zj 42AL
Treasurer Address:
(include city, state, & zip)—�-/t�w // �(/,'L Z�jvf�
Treasurer Phone:
Check One:
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 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, 1 understand that 1 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 CYrt F
I am withdrawing my Certification to remain at or under the $1,000 threshold. I will now bi required
to file the next scheduled report for all contributions and expenditures that have not been evio jqL 17 2019
reported from the beginning of the current election cycle. I further agree to file all future reports r uired
Union Co. Elect(
Date Signed Signature
CRO -3600 Certification of Threshold
NORTH CAROLINA
STATE BOARD OF ELECTIONS
L Certification of Treasurer
This Certification is used by Candidate Committees to appoint a treasurer for the committee. This form is
required and must accompany the Candidate's Statement of Organization.
This Certification is filed at the Board of Elections office where the committee's campaign reports
are filed.
FILED BY:
Candidate Name: KMM
Treasurer Name: K; /n3 p
Treasurer Address: /.:Mz-
(include city, state, & zip) >L� • %���
�.✓G, N /moi• • I
Treasurer Phone:
I certify that the above information is correct, and I, as candidate, appoint said treasurer to personally fulfill
the duties and responsibilities imposed upon the appointed treasurer and subject to the penalties and
sanctions in Subchapter VIII Regulation of Election Campaigns of Chapter 163 of the North Carolina
General Statutes.
1 understand that if the above Treasurer changes, it will be necessary to certify a new treasurer and amend
the existing Statement of Organization within 10 days of the vacancy. I further understand that the above
Treasurer is required to receive training by the State Board of Elections within three months of this
appointment according to Article 163.278.9(k).
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Date Signed1 Signature of Candidate
JUL 17 2019
Union Co. Elect
CRO -3100 Certification of I reasvrer
NORTH CAROLINA
STATE BOARD OF ELECTIONS
Confidential
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: +'iiw,121 NV O61d'Idt7.
Treasurer Name: I \',vt.%- \L
Treasurer Address:
(include city, state, & zip)
Treasurer Phone: -704 -33� - 7/5-3
1 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 deshmate 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 Account Number Account Code
By signing this statement, I authorize agents of the State Board of Elections to inspect all accounts provided.
Date Signed Signature of Candidate or Treasurer
For Candidate Committees Only
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
warrant 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 of Elections to inspect applicable accounts.
7-(0- ic,
D
Date Signed Signature of Candidate o
JUL 1 2019
Union Co. Elections
CRO -3500 Certification of Financia/ Account Information