Harris,Samuel_2022-Stmt-of-OrgStatement of Organization - Candidate Committee IIs. this statement:
1� Now' L3 Amended
Use this form to create a new or update an existing candidate committee.
This form must be accomnanied by form CRO -3500. An amended form is required for each new election year.
1. Committee Information
. Name of Committee
d. ID Number
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b. Mailing Address (include City, State and ZIP Code)
a Date Or ed
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c. Committee Website (Optional)
L Phone Number
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2. Candidate Information
a. FullName
e. Party Affiliation _
b. Mailing Address (include City, State, and Zip Code)
L Office Sought
131H 4W66" 9�. ('16r1rTe NC
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c. Phone Number
d. Email AddressQ
g. Next Election Year
h. Jurisdiction
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E]'Email copy of re ort notices
3. Treasurer Information
4. Assistant Treasurer Information
. Full Name
a. Full Name
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b. Mailing Address (include City, State, and Zip Code)
b. Mailing Address (include City, State and Zip Code)
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c. Phone Number
d. Emaa Address
e. Phone Number d. Email Address
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Send report notices b email es No
Email co of report notices
5. Custodian of Books Information (Keeper of Records
6. Account Information (incl. CRO -3500)
a. Full Name
a. Financial Institution Full Name
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CAMPAIGN F'I'N
Malling Address (include City, State, and Zip Code)
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c. Phone Number
Id.EmailAddress
b. Account Code
1c, Type RECEIV
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®'Lmail copy of report notices
I certify that the Committee is in compliance with all applicable provisions of Article 22A of Chapter 163 of the NC
General Statutes and that no funds are commingled with pr ribited or other non -disclosed funds. I further certify that
this report is complete, true and correct. /
�M Ne ( [�rn-S
Printed Name of Treasurer Signature of Appointed Treasurer Date
I certify that the information above is correct, and I, as the candidate, appoint said treasurer to personally fulfill the
duties and responsibilities imposed upon the appointed treasur r and subject to the enalues in Article 22A of Chapter
163 of the NC General tatutes.
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Printed Name of Candidate Signature of Candidate Date
CRO -2100A NC State Board of Flections NoveMOU zu1 v
Y
CE
us
NORTH CAROLINA
a
�W STATE BOARD OF ELECTIONS
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:
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Committee Name: Ceru �Pf To @lecT .i4rw H nM j Sin%[ I�t�i ,r e/v�So f
Treasurer Name: -Pr4m *V"Y
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Treasurer Address: 1314 Daucu.. KA. /,'tentve-,dJC Zhko
(include city, state, & zip)
Treasurer Phone: -704 Z9?- f3o i
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. `� COUNTY
�UNION
Tvne of account Financial Institution Address Account J@*hhRAIGN FAI"4 `Code
HIN 2
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
I/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 ections to 4ppe plicable accounts.
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ate Signed Signal f andidate or Treasurer
CRO -3500 Certification of Financial Account Information
a NORTH CAROLINA
Q- STATE BOARD OF ELECTIONS
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 filed at the Board of Elections office where the committee's campaign reports
are filed.
FMED BY:
Committee Name:
�L) eleC- -
SWC D A,2f S,
Treasurer Name: --Ca".1 AR rr iS ® r7
Treasurer Address: 13) 4 &taco ,� t � , on r» e_ .1 V C 2d 11 O
(include city, state, & zip)
Treasurer Phone:
UNION COUNTY
FINANCE
2022
Chec e: RECEIVED
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. 163-278.1OA. 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 agre to file all future reports r q'uired.
27L2 Z
Dateigaed Signa
CRO -3600
Certification of Threshold