Clontz,Jerry_2017-CommitteeStatement of Organization - Candidate Committee
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 amendine
Amendment
❑1'. ❑ No
only re-suhmit if annlicablel
1. Committee Information
.c.
. Full Name
ED Number
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. Mailing Address (include City, State and Zip Code)
d. Date Organized
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e.Phone Number
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2. Candidate Information ❑ Candidate's Primary Committee
a. Full Name
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e. Candidate ID Number
f. Party Affiliation
Ondicate Non-partsan if applicable)
b. Mailing Address (in de City, State and Zip Cody,
g. Office Sought
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. Phone Number d. Emil Address
Ir. Nest Election Year
[Jurisdiction
❑Email copy of notices
. Treasurer Information
4. Custodian of Books Information
. Full Name
a. Full Name
b. Mailing Addr (include City, State, and Zip Code)
b. Mailing Address (include City, State, and Zip Code)
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. Phone Number Id. Email Address
c. Phone Numberd.
Email Address
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-
1 prefer to receive notices by emailYes No
❑ Email co of notices
5. Assistant Treasurer Information '�Add
aa�-s
. Full Name �rcemove
6. Account Information (incl. CRO -3500) Add
a. Financial In%loUtlon Full Name ❑ Remove
b. Mailing Address (include City, State, and Zip Code)
b. Purprne
. 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.
— �Z
rinted Name of Signer Signal f Appointed TreasureDate
CRO -2100A NC State ((Pard of Flections July 2011
Kim Westbrook Strach
Executive Director
North Carolina
State Board of Elections
441 N Harrington Street
Raleigh, NC 27603
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:
Treasurer Name:
Treasurer Address:
(include city, state, & zip) --a At no �-- /Vbi "I/ D
Treasurer Phone: 70 r� lrC_7/1oLV
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 V111. 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. 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).
7 �w/;7 C
Date Signed Signature of Candi tee
Note: This Certification is to be filed at the Election Board where the committee's campaign reports are filed.
CRO -3100 Certification of Treasurer July 2014
North Carolina
State Board of Elections
441 N Harrington Street
Raleigh, NC 27603
Kim Westbrook Strach Mailing Address
Executive Director PO Box 27255
Raleigh, NC 27611-7255
(919) 733-7173
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:
Treasurer Name:
Treasurer Address:
(include city, state, & zip)
Treasurer Phone:
I certify that the information provided below is we 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 desiotate below an account code (anv 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.
By signing this statement, I authorize agents of the State Board Qf Elections to inspect all accounts provided.
�lL17
Date Signednature -or Candidate Treasurer
For Candidate Committees Only
Lit/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 Board Elections
CRO -3500 Certification of
2014
4
North Carolina
State Board of Elections
441 N Harrington Street
Raleigh, NC 27603
Kim Westbrook Strach
Executive Director
Matting 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 board of supervisors, or
sanitary district board.
This Certification is tiled at the Board of Elections office where the committee's campaign reports
are riled.
FILED BY:
Committee Name:zlft-r4.cw 51
Treasurer Name:
Treasurer Address:1.I).r�t0a./
(include city, state, & zip) yr/� G,
Treasurer Phone: ��c� ��� ?�/��—/
ChecXOne:
✓ I 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, 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 further agree to file all future reports required.
7 ��,L
Date Signed Signet
CRO -3600 Certification of Threshold July 2014