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Bention,Jimmy_2021-Org-ReportAmendment Disclosure Report Cover o Yes 92'r_',o _ Use this form for general report and committee information, must be signed and submitted along N\ till other detailed forms. Do not use 1111, (01111 lu 11)dWc infimndli0m. 1. Committee Information a/.Name C. ID ,Aumber 'Pull CC, ' ln e e. C_ L 4 keve b. Mailing Address (include City, State and Zip Code) d. Date Filed -o3- Tvc 1+c - r 5+rcz t Il at. 11� p 1 1O,%^vC, /Vc- zC�Ito e. Phone Number 2. Report Year 3. Period Start Date (quadd yy) 4. Period End Date imtrudd/vv) �• "Treasurer Full Name .zoo_ �► zt�%a�� e�t�, C_ .,,. c,., 6. Tyre of Cotmnittee (Check One) 9. Type of Report (c he ck un(p one npe of rtpor( from rate category) andidate Campaign ❑ Party Municipal Stale/County Referendum ❑ PAC ❑Referendum ❑Organizational ErOgamnlional ❑ ul ❑ Independent Expenditure ❑ Joint Fundraiser ❑ Thirty-five day Quarterly ❑ Pre-relerendum ❑ Legal Expense Fund ❑ Pre-primary ❑ First ❑ Final ❑ Preelection ❑ Pre -runoff ❑ Second ❑ Third ❑ Supplemental Final ❑ Annual 7 Type. of Fund (if applicable, check one) ❑ Booster Fund Semi-annual ❑ Fourth ❑ Special ❑ Building Fund ❑ Mid Year Semi-annual ❑ Year End ❑ Mid Year 11). Special Report Name ❑ Other: ❑ Final [j Special ❑ Year End [:I Final S, Num O Fundraisers this Report _ _ _..., _- ❑ Special ' 11. Account Information 11. Account Information a. Financial Institution Fall Name a. Financial Institution Full Name We- b, Purpose c. Account Code It. Purpose c. Account Code y E'C O ti 1 d. Period Begin Balance d. Period Begin Balance Cctn^�r itee s "0' $ CERTIFICATION I certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 22B & 2213-22M 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 and that 1 have been trained by the NC State Board of Elections. W-4054 La Ber`iic,n j4j�.' L. a.b'- II /at./o1! Printed Name of Signer ignature of Appointed Treasurer Date FOR OFFICE USE ONLY Date Received:(W Employee: Delivery Method ❑ Normal Mail ❑ Registered Mail Date Postmarked: Employee: GHTand Delivered Date Scanned: Employee: ❑ Electronically Filed Date Data Entered: Employee: ❑ Signer has not received mandatory training Please Note: This form cannot be used to amend committee information such as the committee address, treasurer, assistant treasurer, custodian of books information, or account information. You must amend the Statement of Organization (CRO -2100A -E) to snake committee changes. CRO -1000 NC State Board of Elections August 2008 Detailed Summar 18eY7 Y ❑ yes 0� Use this form to summarize all disclosure reporting forms and to total monetary infcanmtion 1. Committee Full Name (and Fund "a pllcable) 2. Type of Report _ _ 3. ID Number M + t o L c Itev. tNk(;' Sr O- qft; Ztf10r%C%_1 Start of Election Cycle: January 1, Z D I R Total this Reporting Period Total this Electinon vele 4) Cash on Hand at Start $ $ - RECEIPTS 5) Aggregated Contributions from Individuals (CRO -1205) $ $ 6) Contributions from Individuals (CRO -1210) $ 7) Contributions from Political Party Committees (CRO -azo) $ $ 8) Contributions from Other Political Committees (CRO -1230) $ $ 9) Loan Proceeds (CRO -1410) $ $ 10) Refunds/Reimbursements to the Committee (CROa240) $ $ 11) Other Receipt Sources IIs) Interest on Bank Accounts (CRO -1250) $ $ 11b) Contributions from Not -For -Profit Organizations (CRO -1250) $ $ 11c) Outside Sources of Income (CRO -1250) $ $ I Id) Legal Expense Fund -Other Sources (CRO -1270) $ $ Ile) Exempt Purchase Price Sales (CR04265) $ $ 12) TOTAL RECEIPTS (Add lines 5, 6, 7. 8, 9,10.1 1 a. I I b, I I c, I I d and I I e) $ 5 EXPENDITURES 13) Disbursements 13a) Operating Expenditures K RO-1310) $ $ 13b) Contributions to Candidates/Political Committees (CRO -1310) $ $ 13c) Coordinated Party Expenditures (CRO -1310) $ $ 14) Aggregated Non -Media Expenditures (CRO -131.5) $ $ 15) Loan Repayments (CRO -1420) $ $ 16) Refunds/Reimbursements from the Committee (CRO -1320) $ $ 17) In -Kind Contributions (CRO -1510) $ $ 18) TOTAL EXPENDITURES (Add lines 13a, 13b, 13c, 14, 15, 16 and 17) $ $ 19) Cash on Hand at End (Add lines 4 and 12 together, then subtract line 181 13 Or $13c. (y G ADDITIONAL INFORMATION 20) Non -Monetary Gifts Given to Other Committees (CRO -1330) $ 1) Outstanding Loans (Incl, ones from other campaigns) (CRO -1430) $ 2) Debts and Obligations owed by the Committee (CRO -1610) $ 23) Debts and Obligations owed to the Committee (CRO -1620) $ 24) Account Transfers Within the Committee (CRO -1720) $ 5) Administrative Support (CRO -1710) $ $ 26) Forgiven Loans (CRO -1440) $ 7) 48 -Hour Notice Reports Sum (CRO 2220) $ 8) Contributions to be Refunded (CRO -1215) $ N 2 CRO -1100 NC State Board of Elections Au ust 2008 Union Co. k�lections Amendment Contributions from Individuals Pg _ of ❑ Yes No Use this form to report individual C0I1l1 Ibllllons over $50 or contributions under $50 if form CRO 1205 is not used dRand if applit I L{� T C,gptributor.Jnforruatiou ❑ Add_ -❑ Remove ;t a. Full Name, Mailing Address & Phone b. Job Tide/Profession d. Comments (include city, state, & zip) R� . ]r M M �� • &n� �p/tl S S - c. Employer's me/Specifle Field 3 r Street ©C,,�L Y" C w n ^ e t C_„a.t e. Election Sum to Date -_ C Prior g. Account Code h. Form of Payment i, ln•Kind Description J. Date (mm/ddlyyyy) ILAmount ❑Csrl a -ab -anal $loo.a� ❑ $ ❑ $ 3. Contributor lnl'mrnlation ❑ Add ❑ R' '- -oa`_ a. Full Name, flailing Address & Thune (include city, state, & zip) �, q To y 0. L-- Pn'F t [J/� 3©A ele ,MK/ o ,,j &0 e N �p �' b. Job'I ille/Profession /� / ,ten r d. Continents G Employer's Name/Specific Field i f 1) " I� I/ , e. Election Sum to Date eU CJ u $ / &. . Prior g. Account Code h. Form of Payment (2�si i. In -Kind Description J. Date (mm/dd/yyyy) k Amount ❑__j OY ❑ $ ❑ $ 3. Contributor Information ❑ Add ❑ Rcn:oce a. Full Name, flailing Addrese & Plwne (include city, state, & zip) b. Job Title/Profession d. Comments c. Employer's Name/Specific Field e. Election Sum to Date . Prior ❑ g. Account Code It. Form of Payment 1. In -Kind Description J. Date (mm/ddlyyyy) Is. Amount $ ❑ $ ❑ 5 4. Total only this Page 5 5. Total of ALL CRO -1210 Pages (This firm mus( he on line b of Detailed Jumnmry Page CNO-111/0) 5 n 9 2021 CRO -1210 N(Sone lio.irJ of IiIcCGons_R9CtP@4>'s Uf;.