Smith,Brandi_2021-Stmt-of-OrgStatement of Organization - Candidate Committee
Use this form to create a new or update an existing candidate committee.
This form must be accomnanied by form CRO -3500. An amended form is rc
Is s statement:
New 0 Amended
for each nets election year.
d. ID \umber _
qTM g
c. Committee Website (Optional) 1 _7Jf. Phone Number
.1; n IAC . �,�� 913 A
a. Full Name _ e. Party Affiliation
Sri `} -Lvwpu
. Mailing Address (include City, State, and Zip Code) f. Office Sought
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. Phon umber it. Email Add eu g. NexxtlElection Year Its. Jurisdiction
7 CrJI'nIAC, COn /�-
0 Email comv of remort notices
Full Name
u
rv\.1
`1 6::)U I-AUl,,-- - 1LkJ r\ CT'
CAMPAIGN FINANCE
2021
c. Phone Number
I& Email Address
c. Phone Number
it. E Address
70
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RECEIVED
Send re or[ notices b email
Yes Ej No
L3 Email copy of report notices
5 Custodian of Books Information
(Keeper of Records
6. Account Information fmcf. CRO -3500)
a. 1 Name
a. Financial Institution Full Name
of
_ __-
_ n _ , . _
b. Mailing Addr'b include City, Sfate, and Zip Code)
S �• t
\C��
I to Y_0k
c. Phone Number Id. Email Address
r Email copy of report notices
I certify that the Committee is in compliance with all apl
General Statutes and that no funds are commingled with
this report is complete, true and correct.
Printed Name of Treasurer
I certify that the information above is correct, and
.lubes and responsibilities imposed upon the of
163 of the NC General Statutes.
Account Code
provislot 22A of Chapter 163 of the NC
d or other non -disclosed t er certify that
rc a cd Treasu r
dffM appDtffMid treasurer to personally Will the
and subject to the penalties in Article 22A of Chapter
VillrokpFenlrdidate pate
' NORTH CAROLINA
�� STATE BOARD OF ELECTIONS
Certification of Financial Account Information I
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:V�Q
Treasurer Name: _Lranrill
Treasurer Address: l Kr� C�i .
(include city, state, & zip) 1 V-10 L'Q kDc QL�'-
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 (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.
TvDe of account Financial Institution Address
1� -
By si m this statemM I authorize agents of the
g
Date Signed
For Candidate Committees Only
Account Number Account Code
In lieu of providing account information, I certify that this committee will not raise any mon 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
V*M NORTH CAROLINA
�r STATE BOARD OF ELECTIONS
I 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:
Ili�a trl rt t ��Wl.l T "-J
Committee Name:
Treasurer Name:
If Candidate is own treasurer, designate an agent to carry out designations:
Committee ID #: G -,TI A W
Level Registered: [State] [County] If county, specify:
1, `��c� 1 i`l'� , hereby direct that in the event of my death or incapacity all
(Name of Candidate)
Rinds 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§1663-278.16Bta))
1. L/ (�tt
2.
3.
Plan for Disbursement (eg. Amount or %)
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 d with the Committee
records.
Signature of Candidate:
Date:
CRO -3900
Candidate Designation of Committee Funds