Palandri,Gina_2022-Stmt-of-OrgStatement of Organization - Candidate Committee Is this staent:
❑ 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 vear.
1. Committee Information
a. Name of Committee
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d. ID Number 19
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b. Mailing Address (include City, State and Zip Code)
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a Date O anlzed
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. Committee Website (Optional) r % E Phone Number
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2. CandlidaRe Information
a. Full Name
e. Party Affiliation
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b. Mailing Address (include City, State, and Zip Code)
f. Office Sought
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. Phone Number
d. Email Address
g. Neat Election Year
h. Jurisdiction
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❑ Email copy of report notices
3. Treasurer Information
4. Assistant Treasurer Information
a. Full Name
a. Full Name
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b. Mailing Address (include City, State, and Zip Code) _
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It. Mailing Address (include City, State and Zip Code)
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c. Phone Number Id. Email Address
c. Phone Number
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Id. Email Address
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5. Custodian of Books Information (Keeper of Records
6. Account Information (incl. CBO -3500)
a. Full Name
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a. Financial Institution Full Name
b. Mailing Address (include City, State, and Zip Code)
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c. Phone Number
Id. Email Address
It. Account Code
c. Type
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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 Tignature 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. t
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Printed Name of Candidate Signature of Candidate Date
CHH -2106A NC State Board of Elections November 2019