Hall,Jason_2021-CommitteeUNION COUNTY
CAMPAIGN FINANCE
APR 2 0 2021
Statement of Organization - Candidate Committee is this statement:
Use this forth to create a new or update m existing candidate c
8ntrtptteZ" E I V E NeW 0 Amended
This form must be accompanied by forth CRO -3500. An amended form is required for each new election year.
. Committee Information
Name of Committee
HALL 4 Waxhaw
it. ID Number
Muslim Address Include City, State mud Zip Code
c. Date organized
Apri.l YL; 2021
10o Waxhawparlewall, KKit 606
-
Commom wei nih (opdouQ
E Phone Number
www.hall4waxhaw.00nt.
70+-265-57127
Fall Name
Party Affffintion
)asow MOOLod HAA
NowPartisaw
Main" Address (include City, Stute, and Zip Code)
Office Sought
ion Waxhaw parkwaU, KKit 606
Way -haw, Na 281YL3
WAxhAW (:ONt"VASiOwtr
. Phone Numberd
. Emil Address,Nest
Election Year
1h.Jurimficithom
y0+0 -55n58 jttso,,@hall.lwaxhaW.00tm.
Email co of re ort notices
2021
wyaow COKntIu.
I Absttiet9
A.Treasturer Information
4. Assistant Treasurer Information
Fall Name
Dav a.eL 1=. L.Lsewsie%
2. Full Name
Sante as TYeaskyer
IL Mailing Addrss (include City, Sate, and Zip Code)
It. Malting Addres (inch de City, State am! Zip Code)
loo Waxhaw pariewad, WYA 606
WaXhaw, NC 28173
Phone Number Id. Email Address
c Phone Number
d. ENO Address
70+-2s3-sy9; daw@katl twaxhaw.00w.
Send restart notices by email JKI Yes ETNo
Email co of re rt notices
f Books Information (Keeper of Records
Fun Name
.Account In ormation (incl. CRO -3500
Financial Institution Full Name
Sarwe as TYeasttrer
1=1 Jpch ThLrol 1&AW►2
Mailing Address (include City, Stow, mad Zip Code)
8100 KemsL"tow Ar.
Waxhaw, NC 281YL3
Phone Number
d.Esan Address
b. Account Cade
Type
Email copy of notices
HWXW01
C �G�/✓1
I certify that the Committee is in compliance with all apippeafile provisions of Article 22A of Chapter 163 of the NC
General Statutes and that no funds are commingled wi pro ibited or -discl funds. 1 further certify that
this report is complete, true and correct. ^
DavaeL 1=. t-isewskL�-
Printed Name ofTreasurer Sigumniq orbateA inted Tress
rtify that the information above is correct, and 1, as the candidate, appoint said treasurer to personally fu1811 the
ies and responsibilities imposed upon the appoin asttteran ubject to the penalties in Article 22A of Chapter
L16�3of the NC General Statutes.
)asow MDCLD j Mall LIA 211 -LI
Printed Name of CandidateOsnaturcif Candidate
CRO -2100A NC tate BomdofE tions November 2019
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:
F+MLL 4 WaAkaw
DRK%eL i=. L sewski
Treasurer Address: :00 Waxhaw ParkwaH, wr.%t 606. Waxhaw NC 29i9-3
(include city, state, & zip)
Treasurer Phone: X04-255�f8
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 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.
eaeodt ",&W Mt I " -h" A.1, I e1
Bysigning thi statement, I authorize agents of the State
Z
D. Sigaed
For Candidate Committees Only
Account Number Account Code
M.
of EIZc o to inspect all accounts provided.
J 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 of Elections to inspect applicable accounts.
Date Signed Signature ofCmdidate or Treeamer
UNION COUNTY
';AMPAIGN FINANCE
CRO -3500 Certification ofhinancial.Iecouetinionnation APR 20 2021
RECEIVED
UNION COUNTY
CAMPAIGN FINANCE
Candidate Designation of Committee Funds
This forms is used by candidate committees only and allows the candidate to designate in the event of their death,
how the committee's funds are to be disbursed using the eight allowable methods outlined in 163-278.16B(a).
This Designation Is filed at the Board of Elections office where the committee's campaign reports are filed.
Candidate Name: lasow MCCIow "au
Committee Name: I-laU. 4 Waxhaw
Treasurer Name: Dawi.el, l=. l ist%M5kir
If Candidate is own treasurer, designate an agent to carry out designations: _
Committee ID #:
Level Registered: [State] [County] If county,
I, )asow MCCIo ffayl U. hereby direct that in the event of my death or incapacity all
na
(Naoffends )
funds remaining in my Campaign Committee account(s) (after payment of permitted outstanding
debts or reasonable expenses for winding up the Committee or closing office) be paid in the
following manner as permitted by N.C. Gen. Stat. 163-278.16B(a).
Name of Entity
(sda*!� §163-2 78. f da(a))
1. Waxhaw Athletic ASsoeirG60K
2.
3.
By signing this form, I certify that the
Gen. Statute 163-278.16B(a). A copy
records. /
Signature of Candidate:
i
CRO -3900
Plan for Disbursement (ee. Amount or %)
entities are eligible beneficiaries under N.C.
n should be maintained with the Committee
Candidate Designation at Committee f imds