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Record,James_2021-CommitteeStatement 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 C 7mmittee it. In Number eux; l , A, b. Mailing Address (in ude City, State and Zip Code) e. nate pritaltized }3a t L'csti C ✓r t dax % �c 2�u } L r`3 2a't'3— c. Committee Website (Optional) f. Phone Number 2. Candidate Information a. Full Name e. Party diction + b. Mailing Address (include City, State, and Zip Code) V '7V -r, �_1NC- Z 9 L Office Sought /✓�a�cr/ c . Phone Number it. Email Address g. Next Election Yeah. Jurisdiction qyn, 2ica'-- /SSj (cc.�-�l�iC�! 4� irc_c^'� J - ..-( nice snrtl� — ❑ Email copy of report notices 3. Treasurer Information 4. Assistant Treasurer Information a. Full Namef a. Full Name /Address b. Mailing (i elude City, State, and Zip Code) b. Mailing Address (include City, State and Zip Code) d 'rrr sQ I Ive - 7,%,O- S c. Phone Number it. Email Address c. Phone Number it. Email Address q s3-2V�FJ ryir Cj(\,i,sS< rrc ✓-. �r � Jb Send report notVices email ❑ Yes ❑ No ITEmail copy of report notices 5. Custodian of Books Information (Keeper of Records 6. Account Information" Ouel. CRO -3500) a. Full Name a. Financial Institution Full Name b. Mailing Address (include City, State, and Zip Code) c. Phone Number d. Email Address b. Account Code c. Type ❑ 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 prop ited or other non -disclosed funds I further certify that this report is complete, true and correct. Ind. cp t� 41140 C7 /02i42( inted N me of Treasurer Signa re of A pointe urer Date I certify that the information above is correct, and I, as the candidate, appoint said treasurer ersonally fulfill the duties and responsibilities imposed upon the appointed treasurer ad r[blecct o e penalties in Article 22A of Chapter 163 of the NC General -Statutes, t �"l — l-� z D rX, Printed Name of Candidate Signature of ndidate ate CRO -2100A NCS e Board of Elections November 2019 ©l NORTH CAROLINA STATE BOARD OF ELECTIONS I Certification of Threshold I 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: Treasurer Address: (include city, state, & zip) X� Clea` ;,Vw,rw /, it/('_ 2Pi0-�--"/ Treasurer Phone: q 00 — 02 3 — 2i / 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 requited 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 hat have not been previously reported from the beginning of the current election cycle. I further agree Mile11 future re rts required, o G 207a ate Signed Certification of Threshold NORTH CAROLINA g �r 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: n Committee Name: Onlm 0.1, - �i� 4RI -61 e J C 1B Treasurer Name: ctLQ a c e✓% p Treasurer Address: -4-'307 o"c lr R (include city, state, & zip) < Uk N L 2—�604-5 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. Tvpe 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 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 Electio tsect app ' able ace nts. ate Signed Signature of Candidate or Treasurer CRO-3500 Certification of Financial Account Information