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Cleveland,David_2017-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 applicable) 1. Committee Information a. Full Name c. ID Number ,Tbvid CievekcL-iAg;-- ` b. Mailing Address (include City, State and Zip Code) d. Date Organized 3443` t ice k Rd., 1Q _%b-CLl�, 1.IC aSo79 7/)1/17 e. Phone Number Zo4�b�t -lo7oD 2. Candidate Information ❑ Candidate's Primary Committee a. Full Name e. Candidate ID Number f. Parry Affiliation b. Mailing Address (include City, State, and Zip Code) g. Office Sought 3943 Lalte�r(c kd., r.,a,a., %nLAl, c. Phone Number d. Email Address SP . ►►f�� LQ1t� oaf 4 1 1 ' 704-4.11-6TG4� d►d,eVvep+�� ❑ Email copy of notices h. Nest Election Year I. Jurisdiction 3. Treasurer Information 4. Custodian of Books Informati a. Full Name a. Full Name WED `�gvICL �t'`a2tn C`:VPil4� ' 1 LUtI AiL b. Mailing Address (include City, State, and Zip Code) b. Mailing Address (include City, State, and Zi Co 3q%3 Lala Rt r►c (�.�T1d�IQ1 \ \t l�, T9 Union Co. Boar 01 c. Phone Number d. Email Address c. Phone Number d. Email Address loo-laZt-b7op nvLei, cleve I prefer to receive my notices by email Yes No ❑ Email copy of notices 5. Assistant Treasurer Information L]Add ❑ Remove 6. Account Information (incl. CRO -3500) a. Financial Institution Full Name ❑ Add ❑ Remove a. Full Name b. Mailing Address (include City, State, and Zip Code) b. Purpose c. Phone Number d. Email Address c. Account Code d. Type ❑ Email copy 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. ncwA. -7ti 141-7 Printed Name of Signer NSignatum of Appointed Trea ver to CRO -2100A NC State Board of Elections July 2014 [. fTn2 � _ I North Carolina State Board of Elections 441 N Harrington Street Raleigh, NC 27603 Kim Westbrook Stxach�O Executive Director `' V` 10- 00 r o�°t�` n Certification of Treasurer Mailing Address PO Box 27255 Raleigh, NC 27611-7255 (919)733-7173 This Certification is used by Candidate Committees to appoint a treasurer to the committee. This form is required and must accompany the Candidate's Statement of Organization FILED BY: Candidate Name: a -V t CLOke yak" Treasurer Name: meyPAV-,A Treasurer Address: (� 1 p �� �� k (include city, state, & zip) �t��iL7Lc� t (Jc 9-9077 Treasurer Phone: 7p.¢- (.,a„ i —&� 7PP 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. I 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. 1 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). I /17 Ina Da[ Signed Signa ure of Candid& e Note: This Certification is to be filed at the Election Board where the committee's campaign reports are tiled. CRO -3100 Certification of Treasurer July 2014 i North Carolina State Board of Elections O 441 N Harrington Street Raleigh, NC 27603 00 Kim Westbrook St9QIC,`�V Mailing Address Executive D` ✓ PO Box 27255 Raleigh, NC 27611-7255 `(919) 733-7173 j'�cQ oa`ao&E\0011s Mo 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: 1 Committee Name: _ I ,, t a C 6"eJa-,d Treasurer Name: - )A VtA C ",,=" Treasurer Address: 3 L �+� , (include city, state, & zip) �_� �� t ( t 1C dw?? 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 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 }a 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 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 Boardo ecdons 'ns ct applicab ccoun Ir 1 Da[ Si ed Si na of Can t ate or Treasurer CRO -3500 Certification of Financial Account Information July 2014 ilk tie North Carolina State Board of Elections 441 N Harrington Street Raleigh, NC 27603 Kiln Westbrook Strach Executive Director Mailing Address PO Box 27255 Raleigh, NC 27611-7255 (919) 733-7173 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 (ward 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: Treasurer Name: Treasurer Address: (include city, state, & zip) Treasurer Phone: Ch k One: ",1 /T(�P� I certify that this committee intends to neither receive nor expend more than $1,000.QRfw yoga Oj t - ection cycle under the procedures set forth in G.S. 163-278.10A. This certification iiRh'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, I understand that I 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 CYCLE. I am withdrawing my Certification to remain at or under the $1,000 threshold. I will now be required to file the next scheduled report for all contributions and expenditures that have not been previously reported from the beginning of the current election cycle. I f her agree to file all future reports required. J 117 Date/Signed Signature CRO -3600 Certification of Threshold July 2014