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Heintel,Kathleen_2021-Stmt-of-OrgStatement of Organization - Candidate Committee Is this statement: New ❑ Amended Use this form to create a new or update an existing candidate committee. This form must be accompanied by torn CRO -3500. An amended form is required for each new election year. 1. Committee Information a. Name of Committee d. ID Number c�-,� e1 � J�oY bot - b. Mailing Address (iultlude City, State and Zip Code) e. Date Organized C1 V Lf BQAvivavl 1-an6 PDtiyeje, W, aF►,v t 2-Z�-a1 . Committee Website (Optional) E Phone Number 2. Candidate Information a. Full Name _ a Iato M e 0ei videl e. Party Affiliation u�►Iea . Mailing Address (include City, State, and Zip Code) So y} Q,�V iuta hg L&vtt_ Mcnivoe agUo f. Office Sought $oayd v� EJ,(,tea4ia✓7 Alsi(vl+ b c . Phone Number d. Emall Address g. Next Election Year aoa} It. Jurisdiction sib-53m-hbOg kbhelntcl@ mar l.tom ❑ Email copy of report notices 3. Treasurer Information 4. Assistant Treasurer Information a. Full Name a. Full Name KeLNlez,;-7 M-eszl 461 b. Mailing Address (include City, State, and Zip Code) b. Mailing Address (include City, State and Zip Code) gD1-1 PUt I duns L/1 I4onYie$ �/, v c Phone Number d. Email Address c. Phone Number d. Email Address Send report notices by email Q Yes ❑ No El Email copy of ie ort notices 5. Custodian of Books Information (Keeper of Records 6. Account Information (incl. CRoa500) a. Full Name a. Financial Institution Full Name REGEIVED b. Mailing Address (include City, State, and Zip Code) DEC 0 6 2021 c. Phone Number d. Email Address b. Account Code c. Type Union Cooard of Elections ❑ Email 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 prohibited or other non -disclosed funds. I further certify that this report is complete, true and correct. K J h -46t-k 1 Printed Name of Treasurer 6uSignature 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 treasurer and subject to the penalties in Article 22A of Chapter 163 of the NC General Statutes. K �e-"o V-e-1vlJQI Printed Name of Candidate Signature of Candidate Date CRO -2100A tate Board of Elections November 2019 V© NORTH CAROLINA 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: Committee Name: "AIA elvl-W 4, 86G Treasurer Name: Treasurer Address: �V FQ-�y i e— t rA o s ,D (include city, state, & zip) F�1 p yl V P k% 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 Yin 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 f Cctions t9 ' spect applicable accounts. 'D Signed RECEIVED Signature of Candidateor Treasurer DEC 0 6 2021 nn nn� CRO-3500 Cer mcatton o inanctaPAccount Information PTH CAR ELECTI I 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. FILED BY: Committee Name: KaAii U N e 1 vt-i e.) 4y -86E Treasurer Name: VZ+- lee vi +A --i y - e - Treasurer Address: 9 a L� PO,4 t C -t CA(,? s U;q f (include city, state, & zip) UD4 r o P_ MC, R S) 1 D Treasurer Phone: 02 / 4, - X3 6 - qW c Chqpk One: 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 fmance 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 agr a to file all future reports required. Dale Signed RECEIVE6U Signature DEC 0 6 2021 Union Co. Board of Elections CRO -3600 Certification of Threshold