Thomas, Jonathon_2021-Stmt-of-OrgStatement 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 Committee
d. ID Number
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b. Mailing Address include City, State and Zip Code)
e. Date organized
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. Committee Website (Optional)
E Phone Number
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a . Candidate Information
. Full Name
e. Party Affiliation
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b. Mailing Address (include City, State, and Zip Code)
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Phone Number
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d. Email Address
g, Neat Election Year
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❑ Email co of report notices
3. Treasurer Information
J. Assistant Treasurer Information
n. full ]nine ff %
a. Full Name
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
Id. Email Address
c. Phone Number
d. Email Address
Scnd rc tort notices by email EINes No
Ll Email co of re ort notices
.5. Custodian of Books Information (Keeper of Records
6. Account Information f+ncl. CRO -3,f00)
a. Full Name
a. Financial Institution'S
ikrcN Fi1VAME
It. Mailing Address (include City, State, and Zip Code)
c. Phone Number Id. Email Address
11h. Account Code
It. Type
❑ Email copy of report notices
I certify that the Committee is in compliance with all applicaliy provisions of Article 22A of Chapter 163 of the NC
General Statutes and that no funds are commingled with prohi ited r non -disclosed funds. I further certify that
this report is complete, true and correct.
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Printed Name of Treasurer V Signature o Appointed Treasurer I 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 trpsuferand subject to the penalties in Article 22A of Chapter
163 of the NC General Statutes. i
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Printed Name of Candidate Sijnfture of Candidate Date
CRO -2100A NC State Board of Elections November 2019
NORTH CAROLINA
`TAT' STATE BOARD OF ELECTIONS
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: _Jan414, n Roder 4 TAon, a s
Committee Name: TA,o»,as -r..Un,an Lo✓r�
Treasurer Name: -Pq / i Z&ilQ
If Candidate is own treasurer, designate an agent to carry out designations:
Committee ID #:
Level Registered: [State] [County] If county, specify: (/n Ca,
1, Jena ,t4. M R 1 e, 4 Th,„.. , hereby direct that in the event of my death or incapacity all
(Name of Candidate)
funds 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 §163-278.16B(a))
1. SWGe4 U,on IS [,iii can Womfn
2.
Plan for Disbursement (eR. Amount or %)
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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 form should be maintained with the Committee
records.
Signature of Candidate:
Date:
CRO -3900
1/2
Candidate Designation of Committee Funds