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StmtOrgStatement 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 amending Amendment ❑ Ves E. No nnlv re-cnhmit if annlirahlPl 1. Committee Information a. Full Name c. ID Number i'a }} 1 CDIMrYI�AAt2+ I~1 -C -A b. Mailing Address (include City, State and Zip Code) d. Date Otgaaved 'WR 8 UVl ,tt vtyAe- Q>pYe.� c, . 4K D V-1 Y'D e t KLL a-?, l i V q t 6$ � 20 l'-( e. Phone Number (r-toLo -15 3 - Lk rL 2. Candidate Information ❑ Candidate's Primary Committee a. Full Name11 e. Candidate ID .'Number Party Afniationn ii a�rtc=ta f�pn bieAms Vkki,4 -Y ,E IVAVI vtyscLll� b. Mailing Address (include City, State, and Zip Code) g. Offim Sought C1W8 Llr,:uvw'Me- a�rieN 12d. Moe �. S B F0.kV-ke\A! To VV V-' CcLLWNC't� V c. Phone Number d. Email Address 7ay)'151-4-1ga ek�lnd�eY�a grnci,l. h. Next Election Year i.Jurisdiction Q 1 -� OtalN � Email copy of notices 3. Treasurer Information 4. Custodian of Books Inform ion a. Full Name s. Full Name I b. Mailing Address (include City, State, and tip Code),b. Mailing Address (Include CityState, and Zip Code) 40 C3rAe T2 a. as I�llor N.C� B ILO neon Co. Board of Ele- ; c. Phone Number I d. Email Address c. Phoue Number d. Email Address '1.040 'S al"",l"A66ak6iron�ier, coon I prefer to receive my notices by email ® Yes ❑ No ❑ Email copy of notices 5. Assistant Treasurer Information ❑ Add ❑ Remove 6. Account Information (Inst. CRO-350oj Add ❑ Remove s. Full Name a. Financial Institution Full Name V ,legs b. Mailing Address (include City, State, and Zip Code) b. Purpose CArnPn't i n LkA 5 c. Phone Number d. Email Address a Account Code d. Type p� K Checki ln9 [I 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 finds. 1 further certify that this report is complete, true and correct. Alice I- - "Ot bbca l Printed Name of Signer Signature of Appointed Treasurer Date CYRUd I00A NC State Board of Elections July 2014 RE rIVED 0 2017 Union Co. Board of Elections Kim Westbrook Strach Executive Director ding -14 , n 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) Treasurer Phone: I certify that the above information is correct, and 1, 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). Daze Signed Signature of Candidate 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 1014 RECEIVED JUL 2 6 2017 Union Co. Board of Elections Kiat Westbrook Strach Executive Director rte` 33aY� � 4 North Carolina State Board of Elections 441 N Harrington Street Raleigh, NC 27603 Mailing 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 filed at the Board of Elections office where the committee's campaign reports are filed. FILED BY: Committee Name: Treasurer Name: 1 i Q JA A b ba t Treasurer Address: (o ag- k4 �A . G OL-st (include city, state, & zip) o vy �� Treasurer Phone: (I C) H ) 7 0� �k, — Check 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 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 7t hav not been previously reported from the beginning of the current election cycle. I f"er agree to fil all ure reports required. a Date Signed ralfiMTOM Certification of Threshold �tgnamre r July 2014 VI `(cy RECEIVED jU!L 2 6 2017 Union Co. Board of Elections Kim Westbrook Strach Executive Director G I�% North Carolina State Board of Elections 441 N Ha¢ington Street Raleigh, NC 27603 Mailing Address PO Box 27255 Raleigh, NC 27611-7255 (919) 733-7173 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: r�1 / 1 1 Committee Name: t oVnmi�}1�Ie JCV E%C{ _aAVAC-in �K� elvx5 tVLS1eY Treasurer Name: ����� ► L a 10 b a I Treasurer Address: Zrle,� �tRA - E 4S k (include city, state, & zip) M o yiy-n-e, 1L G a9 i L 0 Treasurer Phone: �t p�) 01, 5 3- L4 8 5 ri 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 (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. Tyne 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 Signkd Signature o andida a or reams V For Candidate Committees Only 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 CRO -3500 Signature of Candidate or Treasurer Certification of Financial Account Information July 2014 ' alow By signing this statement, I authorize agents of the State Board of Elections to inspect all accounts provided. -Date Signkd Signature o andida a or reams V For Candidate Committees Only 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 CRO -3500 Signature of Candidate or Treasurer Certification of Financial Account Information July 2014