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Bention,Jimmy_2022-1st-qtrAmendment Disclosure Report Cover I ❑ Yes ® No Use this form for general report and committee information, must be signed and submitted along with other detailed forms. Do not use this form to update information CRO -1000 NC State Board of Elections August 1. Committee Information a. Full Name c. ID Number Committee to Elect Rev. Bention, Sr. It. Mailing Address (include City, State and Zip Code) d. Date Filed 302 Tucker Street 05/09/2022 Monroe, NC 28110 e. Phone Number 704-572-0879 2. Report Year p 3. Period Start Date (mm/dd/yy) 4. Period End Date mm 5. Treasurer Full Name 2022 01/01/2022 0130 2022 Latoya L. Bention 6. Type of Committee (Check One) 9. Type of Report (check only one type o re ort om one category) ® Candidate Campaign ❑ Party F ]PAC [jReferendum Municipal state/County Referendum E]Organizational ❑ Organizational ❑ Organizational Independent ❑ ,loin Fundraiser ❑ Expenditure ❑ Thirty-five day Quarterly ❑ Pre -referendum ❑ Legal Expense Fund ❑ ❑ ❑ Pre-primary Preelection Pre -runoff Semi-annual ® First ❑ Second ❑ Third ❑ Fourth ❑ Final ❑ Supplemental Final ❑ Annual ❑ Special 7. Type of Fund (ifappticabte, check one) ❑ 'Booster Fund' ❑ Building Fund ❑ Mid Year Semi-annual 10. Special Report Name ❑ Other: ❑ Year End ❑ Mid Year ❑ Final ❑ special ❑ Year End ❑ Final ❑ Special S. Number of Fundraisers this Report 0 ll. Account Information 11. Account Information a. Financial Institution Full Name a. Financial Institution Full Name Wells Faro It. Purpose c. Account Code It. Purpose i Account Code Election 104 MAY 10 2022 Committee d. Period Begin Balance Period Begin Balance Donations Union Co. Election $ 287.41 $ 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 and that I have been trained by the NC State Board of Electi ins. L4+ofc.- L3eti+;ar Printed Name of Signer lam ncmtl St�gnature of Appointed Treasurer ao0a Date FOR OFFICE USE ONLY Delivery Method Date Received: � a' Employee: ❑ Normal Mail Date Postmarked: Date Scanned: I �' � ❑ Registered Mail Employee:j®71 Hand Delivered Electronically Filed Employee: ❑ Signer has not received icy mandatory training Date Data Entered: Employee: 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 make committee changes. CRO -1000 NC State Board of Elections August Amendment Detailed Summary ❑ Yes ® No Use this form to summarize all disclosure reoortine fortes and to total monetary information. 1. Committee Full Name (and Fund ifapplicable) 2. Type of Report 3. ID Number Committee to Elect Rev. Bention, Sr. First Quarter Report Start of Election Cycle: January 1, 2022 Total this Reporting Period Total this Election Cycle 4) 5) 6) 7) 8) 9) 10) 11) Cash on Hand at Start Aggregated Contributions from Individuals Contributions from Individuals Contributions from Political Party Committees Contributions from Other Political Committees Loan Proceeds Refunds/Reimbursements To the Committee Other Receipt Sources Ila) Interest on Bank Accounts I lb) Contributions from Not -for -Profit Organizations I le) Outside Sources of Income lid) Legal Expense Fund — Other Sources 11 e) Exempt Purchase Price Sales (CRO -1105) (CRO -1210) (CR04210) (CRO -1230) (CRO -1410) (CRO -1140) (CRO -1150) (CRO -1150) (CRO -1150) (CRO -1170) (CRO -1165) $ $ 287.41 335 $ $ 0 335 $ 2,270 $ 2640 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 12) TOTAL RECEIPTS (Add lines 5, 6, 7, 8.9, l0, Ila, Ilb, Ile, lldand Ile) EXPENDITURES _ . 13) Disbursements 13a) Operating Expenditures (CRO -1310) 13b) Contributions to Candidates/Political Committees (CRO -1310) 13c) Coordinated Party Expenditures (CRO -1310) 14) Aggregated Non -Media Expenditures (CRO -1315) 15) Loan Repayments (CRO -1420) 16) Refunds/Reimbursements From the Committee (CRO -1320) 17) In -Kind Contributions (CRO -1510) $ 2,605 $ $ 2,975 _ . 305.51 $ 249.51 $ $ $ $ 26.59 $ $ $ $ $ $ $ $ 18) TOTAL EXPENDITURES (Addlinesl3a. 13b, 13c, 14.15.16and17) $ 249.51 $ 332.10 19) Cash on Hand at End (u,1 [::,, a,»,d 11 mKelhe,. rhen,nm uct lie 181 $ $ $ 2,642.90 $ 2.642.90 'i i ADDITIONAL 20) 21) 22) 23) 24) 25) 26) 27) 28) INFORMATION n� Non -Monetary Gifts Given to Other Committees Outstanding Loans (incl. ones from other campaigns) Debts and Obligations owed By the Committee Debts and Obligations owed To the Committee Account Transfers Within the Committee Administrative Support Forgiven Loans 48 -Hour Notice Reports Sum Contributions to be Refunded (CRO -1330) (CRO -1430) (CRO -1610) (CRO -1610) (CRO -1710) (CRO -1710) (CRO -1440) (CRO -1110) (CRo-1215) $ $ $ $ $ $ $ $ $ $ $ CRO -1100 NC State Board of Elections August 2008 Amendment Aggregated Contributions from Individuals Page I of I ❑ Yes ® No Optional form used to report NC Contributions From Individuals of $50 or less 1. Committee Full Name and Fund ifapplicable) 2. ID Number Committee to Elect Rev. Bention, Sr. 3. Contributor Information a. Amend b. Account Code c. Form of Payment d. In -Kind Description e. Date mm/dd/ E Amount Add 104 Credit Card N/A 2/18/22 $ 50 Remove Add 104 Credit Card N/A 1/9/22 $ 5o ❑ Remove Add 104 Credit Card N/A 1/11/22 $ 10 Remove ® Add 104 Credit Card N/A 1/12/22 $ so Remove ® Add 104 Credit Card N/A 1/13/22 $ 25 Remove Add 104 Credit Card N/A 1/15/22 $ 25 Remove Add 104 Credit Card N/A 1/21/22 $ 25 Remove Add 104 Credit Card N/A 1/28/22 $ 50 _- Remove Add 104 Cash N/A 1/14/22 $ 50 Remove ❑ Add $ ❑ Remove ❑ Add $ ❑ Remove ❑ Add $ ❑ Remove ❑ Add $ Fj Remove Add $ Remove Add $ Remove Add $ ❑ Remove Add $ ❑ Remove ❑ Add $ ❑ Remove ❑ Add $ Remove Add $ F1 I Remove Add $ Remove Add $ ❑ I Remove 4. Total only this Page $ 335 5. Total of ALL CRO -1205 Pages $ 335 (This line must be on fine 5 oJDetailed Summary Page CRO -1100) CRO -1205 NC State Board of Elections Apd _00 Amendment Contributions from Individuals Pg of 5 ❑ Yes ® No Use this form to report individual contributions over $50 or contributions under S50 if form CRO 1205 is not used 1. Committee Full Name and Fund if applicable) 2. In Number Committee to Elect Rev. Bention, Sr. 3. Contributor Information ® Add ❑ Remove a. Full *same. Mailing .Address & Phone (include city, state. & zip) b. Job Title/Profession d. Comments Retired Joe Pomykacz 9113 Yellow Pine Ct Waxhaw, NC 28173-8375 (704) 591-8040 c. Employer's Name/Specific Field e. Election Sum to Date $ 0 E Prior g. Account Code It. Form of Payment i. In -Kind Description j. Date (mm/dd/yyyy) k. Amount ❑ 104 CreditCard N/A 1/8/22 $ 100 ❑ $ ❑ $ 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) It. Job'ritle/Profession it. Comments Producer / Cohost Tricia Rana 3214 Hartford Way Matthews, NC 28104-7025 (617) 930-9703 e. Employer's Name/Specific Field The State Of Union County e. Election Sum to Date $ 0 C Prior g. Account Code It. Form of Payment i. In -Kind Description J. Date (mm/dd/yyyy) k. Amount ❑ 104 CreditCard N/A 1/8/22 $ 100 ❑ $ 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession it. Comments e. Election Sum to Date $ 0 Unemployed Heather Morrisette 3205 Hartford Way Matthews, NC 28104-7025 (919) 9304158 e. Employer's Name/Specific Field f. Prior g. Account Code It. Form of Payment i. In -Kind Description J. Date (mm/dd/yyyy) k. Amount ❑ 104 CreditCard N/A 1/12/22 $ 100 ❑ $ ❑ $ 4. Total only this Page $ 300 5. Total of ALL CRO -1210 Pages $ 2,270 (This line tmtst be on line 6 of Deraited Summary Page C110-1100) CRO -1210 NC State Board of l.lections April 21)(17 Amendment Contributions from Individuals Pg z or 5 ❑ Yes ® No Use this form to report individual contributions over $50 or contributions under $50 if fonn CRO 1205 is not used 1. Committee Full Name and Fund ifapplicable) 2. ID Number Committee to Elect Rev. Bention, Sr. 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing .Address & Phone (include city, state. & rip) b. Job Title/Profession d. Comments Tax Accountant Maria Reid 1116 Deep Hollow Ct Waxhaw, NC 28173-6759 (617) 953-7361 c. Employer's Name/Specific Field e. Election Sum to Date $ 0 f. Prior g. Account Code Is. Form of Payment L In -Kind Description J. Date (mm/ddlyyyy) L Amount ❑ 104 CreditCard N/A 1/21/22 $ 100 ❑ $ ❑ $ 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession d. Comments Retired John Delph 6914 Cinder Run Waxhaw, NC 28173-9745 (803) 280-1953 c. Employer's Name/Specific Field e. Election Sum to Date $ 0 C Prior g. Account Code h. Form of Payment 1. In -Kind Description j. Date (mm/dd/yyyy) k. Amount ❑ 104 CreditCard N/A 1/28/22 $ 100 ❑ $ 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & tip) b. Job Title/Profession d. Comments Retired Darryl Mabe 4705 Crestwood Dr Monroe, NC 28112-8613 (704) 242-0400 c. Employer's Name/Specific Field e. Elertion Sum to Date $ 0 f. Prior g. Account Code Is. Form of Payment i. In -Kind Description j. Date (mm/dd/yyyy) L Amount ❑ 104 CreditCard N/A 1/31/22 $ 100 ❑ $ ❑ S 4. Total only this Page $ 300 5. Total of ALL CRO -1210 Pages $ 2,270 (This line num beon Grte 6 of Detailed Sununaq Page CB0.1100) CRO -1210 NC State Board ut lilections April 2007 Amendment Contributions from Individuals Pg 3 of 5 ❑ fes ® No 1 iqe this form to renom individual contributions over $50 or contributions under $50 if fort CRO 1205 is not used 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Rev. Bention. Sr. 3. Contributor Information ® Add ❑ Remove a. Full Name, flailing Address & Phone (include city, statq & rip) b. Job Title/Profession d. Comments Pastor Jimmy H. Bention, Sr. 302 Tucker Street Monroe, NC 28110-3122 (704) 572-0872 a Employer's Name/Specific Field MCC/Temple COGIC e. Election Sum to Date $ 130 E Prior g. Account Code h. Form of Payment I. In -Kind Description j. Date (mm/dd/yyyy) is. Amount ❑ 104 CreditCard N/A 1/8/22 $ 10 ❑ 104 CreditCard N/A 2/19/22 $ 10 3. Contributor Information ® Add ❑ Remove a. Full Name, )tailing Address & Phone (include city, state, & rip) b. Job Title/Profession d. Comments Retired Thomas Leitner 501 S Church St Monroe, NC 28112-5614 (980) 721-5476 c. Employer's Name/Specific Field e. Election Sum to Date $ 0 f. Prior g. Account Code It. Form of Payment I. In -Kind Description J. Date (mm/dd/yyyy) h. Amount ❑ 104 Check N/A 2/9/22 $ 100 ❑ $ 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession d. Comments Pastor Tommie A Murphy 9100 Woodhall Lake Dr Waxhaw, INC 28173-6864 (704) 299-1947 c. Employer's Name/Specific Field New Bethel COGIC e. Election Sum to Date $ 0 f. Prior g. Account Code Is. Form of Payment i. In -Kind Description j. Date (mm/dd/yyyy) It. Amount ❑ 104 Check N/A 2/10/22 $ 500 4. Total only this Page $ 620 5. Total of ALL CRO -1210 Pages $ 2,270 (This line must be on fine 6 of Demiled Summary Page CRO -1100) CRO -1210 NC State Board of Elections April 2007 Amendment Contributions from Individuals Pg 4 or 5 ❑ ves ® No 1 Ise this form to renort individual contributions over $50 or contributions under $50 if form CRO 1205 is not used 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Rev. Benfion. Sr. 3. Contributor Information ® Add ❑ Remove a. Full Name, )tailing Address & Phone (include city, state, & zip) b. Job Title/Profession d. Comments Retired William Mayes 6716 Old Ridge Rd Waxhaw, NC 28173-9483 (704) 301-5123 c. Employer's Name/Specific Field e. Election Sum to Date $ 0 f. Prior g. Account Code It. Form of Payment I. In -Kind Description j. Date (mm/dd/yyyy) k. Amount ❑ 104 Card N/A 2/19/22 $ 100 ❑ $ ❑ $ 3. Contributor Information Z Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) It. Job Title/Profession d. Comments Mom Andrea Mikels 1300 Venetian Way Drive Waxhaw, NC 28173-8076 (305) 431-0675 c. Employer's Name/Specific Field c. Election Sum to Date $ 0 E Prior g. Account Code h. Form of Payment I. In -Kind Description j. Date (mm/dd/yyyy) k. Amount ❑ 104 CreditCard N/A 2/24/22 $ 100 ❑ $ ❑ $ 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession d. Comments Insurance Property Agent John Ciabattoni 4012 Oldstone Forest Dr Waxhaw, NC 28173 c. Employer's Name/Specific Field e. Election Sum to Date $ 0 E Prior g. Account Code It. Form of Payment I. la -Kind Description j. Date (mm/dd/yyyy) k. Amount ❑ 104 Check N/A 3/3/22 $ 500 ❑ $ ❑ $ 4. Total only this Page $ 700 .5. Total of ALL CRO -1210 Pages $ 2,270 (This line nuuv be on One 6 of Detailed Summary Page CRO -1100) CRO -1210 NC State Board of Flections April 2007 Amendment Contributions from Individuals Pg 5 of s ❑ ves ® No Use this form to report individual contributions over $50 or contributions under $50 if form CRO 1205 is not used 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Rev. Bention. Sr. 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession it. Comments Stay at Home Mom Susan Marciniak 113 Somerled Way Waxhaw, NC 28173-0061 (954) 414-9499 e. Employer's Name/Specific Field e. Election Sum to Date $ 0 E Prior g. Account Code h. Form of Payment i. In -Kind Description I. Date orm /dd/yyyy) k. Amount ❑ 3/4/22 CreditCard N/A 3/4/22 $ 100 ❑ $ ❑ $ 3. Contributor Information ® Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Tine/Profession it. Comments Environmental Designer Noyes Harrigan 5001 Colton Ridge Dr Indian Trail, NC 28079-3414 (980) 229-7898 c. Employer's Name/Specific Field Wildlands Engineering e. Election Sum to Date $ 0 L Prior g. Account Code It. Form of Payment i. In -Kind Description I. Date (mm/dd/yyyy) k. Amount ❑ 104 CreditCard N/A 3/7/22 $ 150 ❑ $ ❑ $ 3. Contributor Information Z Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession it. Comments Engineer Allison Power 1322 Churchill Downs Dr Waxhaw, NC 28173-6585 (440) 796-7315 c. Employer's Name/Specific Field Unemployed e. Election Sum to Date $ 0 E Prior g. Account Code It. Form of Payment 1. In -Kind Description I. Date (mm/dd/yyyy) Is. Amount ❑ 104 CreditCard N/A 03/26/22 $ 100 ❑ $ ❑ $ 4. Total only this Page $ 350 5. Total of ALL CRO -1210 Pages $ 2,270 (This line nuts/ be on line 6 of Detailed Summary• Page CRO -1100) CRO -1110 NC Slate Board of flections April 2007 Amendment Disbursements Pg I of 3 ❑ Yes ® No Use this form to report expenditures from the committee for; operating expenses, contributions to candidate/political rnmfllittP anti rnnrdinnted nam Pxnendltureq 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Rev. Bention, Sr. 3. Type of Disbursement Please use separate CRO -1310 forms for each twe of Disbursement ® Operating Fxpenses ❑ Contributions to CalllbdateS/Political Conunincc,. ❑ Coordinated Party Expenditures 4. Payee Information ® Add Remove a. Full Name, blailing Address & Phone include city, state & z; b. Coordinated Committee Name it. Comments Campaignparmers.com PO Box 118 Still River, MA 01467 617-500-7251 c. Level Registered (Specify) ❑ Federal ® County: ❑ State ❑ Municipality: e. Election Sum to Date $ 0 E Account Code g. Form of Payment It. Purpose Code I. Date (mm/dd/yyyy) j. Amount it. Required Remarks 104 CreditCard O 1/8/22 $49 Website Set Up 104 Credit Card O 1/8/22 $5 Domain Registration 4. Payee Information Add Remove a. Full Name, Mailing Address & Phone include city. state, & zip) b. Coordinated Committee Name d. Comments Campaignpartners.com PO Box 118 Still River, MA 01467 617-500_7251 c. Level Registered (Specify) ❑ Federal ® County: ❑ State ❑ Municipality: e. Election Sum to Date $ 54 E Account Code g. Form of Payment It. Purpose Code 1. Date (mm/dd/yyyy) j. Amount it. Required Remarks 104 CreditCard O 2/8/22 $49 Monthly Website Fee 104 CreditCard O 3/8/22 $49 Monthly Website Fee 4. Payee Information El Add Remove a. Full Name, Mailing Address & Phone include city, state, & zi b. Coordinated Committee Name d. Comments Campaignparmers.com PO Box 118 Still River, MA 01467 617-500-7251 c. Level Registered (Specify) ❑ Federal ® County: ❑ State ❑ Municipality: e. Election Sum to Date $ 152 E Account Code g. Form of Payment h. Purpose Code i. Date (mm/dd/yyyy) j. Amount k. Required Remarks 104 CreditCard O 4/8/22 $49 Monthly Website Fee 5. Total only this Pae $ 201 6. Total of ALL CRO}1310 Pages (This line goes in line 13a of Detailed Sumnurr)' Page CRO -1100 if Operating Expenses) (This line goes in line 136 of Detailed Sunmrarr Page CRO -1100 ifContrib to Candidatev/Polifical Comm) (This line goes in line 13c of Detailed Summan• Page CRO -1100 if Coordinated Part, Expenditures) 7. Pur ose Codes List detailed expenditure code in h. above A* - Media B* - Printing C* - Fundraising D -'I u Another Candidate E - Salaries F* - Equipment G - Political Party H* - Holding Public Office Expenses - Postage J - Penalties K* - Office Expenses Q* - Donation to Legal Expense Fund O* - Other * Codes require detailed explanation in required remarks field k CRO -1310 NC State Board of Flections December 2009 Amendment Disbursements Pg 2 of ❑ Yes Use this form to report expenditures from the committee for; operating expenses, contributions to candidate/political rnmmitteac and rnnrdinated nnrtv exnenditnres. 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Rev. Bention, Sr. 3. Type of Disbursement Ple a use separate CRO -1310 forim for each twe of Disbursement ® Operating Expenses ❑ Contributions to Candidates/Political Committees ❑ C'oordinated Party Expenditures 4. Payee Information E Add ED Remove a. Full Name. !flailing Address & Phone include city, state, & zip) b. Coordinated Committee Name d. Comments Online Platform for accepting donations https://stripe.com/ 185 Berry St #550 San Francisco, CA 94107 c. Level Registered (Specify) ❑ Federal ® County: ❑ State ❑ Municipality: e. Election Sum to Date $ 0 E Account Code g. Form of Payment h. Purpose Code I. Date (mm/dd/yyyy) j. Amount L Required Remarks 104 Bank Draft O 1/8/22 $15.31 Stripe roc ssing fee 104 Bank Draft O 1/20/22 $1.03 Stripe roc ssing fee 4.Payee Information Add Remove a. Full Name, Mailing Address &Phone include city, state, & zip) It. Coordinated Committee Name d. Comments Online Platform for accepting donations https://stripe.com/ 185 Berry St #550 San Francisco, CA 94107 c. Level Registered (Specify) ❑ Federal ® County: ❑ State ❑ Municipality: e. Election Sum to Date $ 16.34 E Account Code g. Form of Payment It. Purpose Code i. Date (mm/dd/yyyy) J. Amount Remarks 104 Bank Draft O 1/25/22 $4.23 ELRequired e essin fee 104 Bank Draft O 2/1/22 $4.95 e essin fee 4. Payee Information Add Remove a. Full Name, Mailing Address & Phone include chy, sate, & zip) b. Coordinated Committee Name d. Comments Online Platform for accepting donations https://stripe.com/ 185 Berry St #550 San Francisco, CA 94107 c. Level Registered (Specify) ❑ Federal ® County: ❑ State ❑ Municipality: e. Election Sum to Date $ 25.52 E Account Code g. Form of Payment h. Purpose Code i. Date (mm/dd/yyyy) j. Amount Remarks 104 Bank Draft O 2/2/22 $3.20 Lk,.Required ssin fee 104 Bank Draft O 2/23/22 $1.75 ssin fee 5. Total oniv this Pae $ 30.47 6. Total of ALL CRO -1310 Pages (This line goes in line 13a of Derailed .Summon Page CRO -1100 if Operating Expenses) $ C r (This line goes in line 13b of Derailed Summary Page CRO -1100 if Contrib to Candidares/Polirical Comm) J (This line goes in line 13e of Demiled Summam Page CRO -1100 if Coordinated Parti, Expenditures) 7. Purpose Codes List detailed expenditure code in h. above A* - Media B* - Printing C* - Fundraising D - To Another Candidate E - Salaries F* - Equipment - G - Political Party H* - Holding Public Office Expenses 1 - Postage 3 - Penalties K* - Office Expenses Q* - Donation to Legal Expense Fund O* - Other * Codes require detailed explanation in required remarks field k CRO -1310 NC State Board of Elections December 2009 Amendment Disbursements Pg 3 of 3 ❑ Yes ® No Use this form to report expenditures from the committee for; operating expenses, contributions to candidate/political .irt—. and r nrdinat,d part,: ev n,ndin rPq 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Rev. Bention, Sr. 3. Type of Disbursement Please use separate CRO -1370 forms for each tipe of Disbursement) ® Operating Expenses ❑ Contributions to ("andidates/Political Commiuees ❑ coordinated Party- Expenditures 4. Payee Information Add Remove a. Full Name, Mailing Address & Phone (include city, stat &zi b. Coordinated Committee Name d. Comments Online Platform for accepting donations https://stripe.com/ 185 Berry St #550 San Francisco, CA 94107 c. Level Registered (Specify) ❑ Federal ® County: ❑ state ❑ Municipality: e. Election Sum to Date $ 30.47 E Account Code g. Form of Payment it. Purpose Cade 1. Date (mm/dd/yyyy) j. Amount k. Required Remarks 104 Bank Draft O 2/24/22 $3.79 Stripe processing fee 104 Bank Draft O 2/28/22 $3.20 Stripe ricessing fee 4. Payee Information Add Remove a. Full Name. Mailing Address & Phone include city, state, & zip) b. Coordinated Committee Name d. Comments Online Platform for accepting donations https://stripe.com/ 185 Berry St #550 San Francisco, CA 94107 c. Level Registered (Specify) ❑ Federal ® County: ❑ state ❑ Municipality: e. Election Sum to Date $ 37.46 E Account Code g. Form of Payment h. Purpose Code i. Date (mm/dd/yyyy) j. Amount k. Required Remarks 104 Bank Draft O 3/8/22 $3.20 Stripe roc ssing fee 104 Bank Draft O 3/9/22 $4.65 Stripe rocessin fee 4. Payee Information Add Remove a. Full Name, Mailing Address & Phone (include city, state &zi b. Coordinated Committee Name d. Comments Online Platform for accepting donations https://stripc.com/ 185 Berry St #550 San Francisco, CA 94107 c. Level Registered (Specify) ❑ Federal ® County: ❑ State ❑ Municipality: e. Election Sum to Date $ 45.31 E Account Code g. Form of Payment h. Purpose Code i. Date (mmldd/yyyy) j. Amount k. Required Remarks 104 Bank Draft O 3/30/22 $3.20 Stripe processing fee 5. Total only this Page F $ 18.04 6. Total of ALL CRO -1310 Pages (This line goes in line l3a of Detailed Summon' Page CRO -1100 if Operating Expenses) $ d - U 9. 5 (This line goes in line 13b of Detailed SummaPage CRO -1100 if Conlrib to CandidateslPolitical Comm) 7 r' (This line goes in line 13c of Detailed Summar' Pone CRO4100 if Coordinated Party Expenditures) 7. Pur ose Codes(List detailed expenditure code in above A* - Media B* - Printing C* - Fundraising D -'1-o Another Candidate E - Salaries F* - Equipment G - Political Party H* - Holding Public Office Expenses - Postage J - Penalties K* - Office Expenses Q* - Donation to Legal Expense Fund O* - Other * Codes require detailed explanation in required remarks Held k CRO -1310 %( �i.n, Board of Elections uecemner zuuv