James, Angelia_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 form CRO -3500. An amended form is required for each new election year.
1. Committee Information
a. Name of Committee
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d. ID Number
b. Mailing Address (include City, State and Zip Code)
e. Date Organized
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e. Committee Website (Optional)
L Phone Number
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2. Candidate Information
a. Full Name
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e. Party Affiliation
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b. Mailing Address (include City, State, and Zip Code)
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E Office Sought
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c. Phone Number
d. Email Address
g. Next Election Year
h. Jurisdiction
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mail Co of report notices
3. Treasurer Information
4. Assistant Treasurer Information
a. Full Name
a. Full Name
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. Mailing Athiress (include City, State, and Zip Code)
b. Mailing Address (include City, State and Tip Code)
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. Phone Number
d. Email Address
c. Phone Number
Email Address
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Send report notices by email Yes ONo
El Email copy of report notices
5. Custodian of Books Information (Keeper of Records
6. Account Information fmcl. CRO -3500)
a. Full Name
a. Financial Institution Full Name
UNION COUNTY
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b. Mailing Address (hu: aiid Zip ode)
JUL 0 7 2021
_Phone Number
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b. Account Code
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❑ 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.
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, Printed Name of Treasurer Si aturc of Apointed Treasurer Date
I certify that the information above is correct, and I, as the candidate, appoi ksaid treasurer to personally fulfill the
duties and responsibilities imposed upon the appointed treasurer and subj t [ the penalties in Article 22A of Chapter
NC General Statutes.
163 of AK
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Printed Name of Candidate Signa Can idate Date
CRO -2100A NC State Board of Elections November 2019
IVOTPE NORTH CAROLINA
STATE BOARD OF ELECTIONS
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:
251(0
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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 desienate 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.
Type of account Financial Institution Address Account Number Account Code
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By signing this statement, I authorize agents of the State Board of E ons to igspeel Jallcco�vided.
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Date SignedSi of C Q ate or Treasurer
For Candidate Committees Only /
O 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' e 1 fiords. I furthermore understand that an audit or investigation could
warrant the probe of anyGpA��that is being used for campaign expenditures.
By signing this statement, I authorize agents of the State Board of Elections to inspect applicable accounts.
JUL 0 7 2021
Date Signed RECEIVED Signature of Candidate or Treasurer
CRO -3500 Certification of Financial Account Information
NORTH CAROLINA
STATE BOARD OF ELECTIONS
Candidate Designation of Committee Funds
This form 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: A4 « 1 a a w, s
Committee Name: 4c, 10-ec. ' Anj-2 N D -4,,t s
Treasurer Name:
If Candidate is own treasurer, designate an agent to carry out designations:
Committee ID #:
Level Registered: [State] [County] If county, specify:
1, N"lxa-e I, cr -To Wits hereby direct that in the event of my death or incapacity all
(Name of Candidate)
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
(Select from §163-27&168(a))
2.
3.
Plan for Disbursement (eg. Amount or %)
10 0/0
By signing this form, I certify that the foregoing entities are eligible beneficiaries under N.C.
Gen. Statute 163-278.16B(a). A copy of this form should be maintained with the Committee
records.
Sign��TY
E
Date: JUL 0 7 2021
RECEIVED
CRO -3900 Candidate Designation of Committee Funds