StmtOrg 7-26-21 Jeff PerrymanStatement of Organization - Candidate Committee I Is t is statement:
NCW ❑ 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: Cdimmitteeln'formatidn' '- '
it. Nome of Committee
d. ID Number
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b. Mailing Address include City, State and Zip Code)
e. Date Organized
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c. Committee Website (Optional)
f, Phone Number
'15-6- 7-2
2. Candidate 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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c. Phone Numbe
'd. Erimil Address
g. Next Election Year
1h. Jurisdiction
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®-Email copy of report notices
3. Treasurer Information
4. Assistant Treasurer Information
a. Fall Naam��e
a. Fall 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. Email Address
c. Phone Numberit. Email Address
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Send report notices by email LIfYes ❑ No
U Email copy of report notices
5. Custodian of Books Information Keefer of Records
6. Account Information (incl. CR- o
a. Full Name
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a. Financial Institution Full Names 777—y
b. Mailing Address (include City, State, and Zip Code) :
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e. Phone Number
Id. Email Address
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 ofTreasurer ib inure of Appo' ed Treasurer Date
I certify that the information above is correct, and 1, 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.
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Printed NameofCandidate Signatureof andidate Date
CRO -2100A k,y tate Board of Elections November 2019
gNORTH 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: kLcdCV ,
Treasurer Name:
Treasurer Address: -71-17
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(include city, state, &zip) (Al4W4A, ,,,Z, A (f �C6
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
funds UNION COUNTY
the political committee and shall not commingle those with any other moneys.
CAMPAIGN FINANPEd
T e of account Financial Institution Address Account Number Account o e
JUL 16 2021
RECkIVFn
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 Onlv
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 Electi nsto i a t applicable accounts.
Date Signed ignature of Can ate or Treasurer
CRO-3500 Certification of Financial Account Information