Wortman,Andrew_2021-CommitteeStatement of Organization - Candidate Committee I Ais statement:
la New Q 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
7 /l0 Zoe/
c. Committee Website (Optional) L Phone Number
76Y 8190<18'
2• Candidate Information
a. Full Name
e. Party Affiliation
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b. Mailing Address (include City, State, and Zip Code)
£ Office Sought
20/2 01 IL 4a,J Afe roK &. /1'1r.1741Jw
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c. Phone Number
d. Email Address
g. Next Election Year
h. Jurisdiction
-Wk,09124
❑ -mail copy of report notices
3. Treasurer Information
4. Assistant Treasurer Information
a. Full Name
a. Full Name
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b. Mailing Addre (_include City, State, and Zip Code)
b. Mailing Address (include City, State and Zi Code)
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c. Phone Number
d. Email Address
c.Phone Number d.Email Address
701/ 70 OS/0
/4uZfre,1(cum q.«a/�Ca
Send report notices by email Yes UNo
U Email copy of report notices
5. Custodian of Books Information (Keeper of Records
6. Account Information (incl CRO -3500)
a. Full Name
a. Financial Institution Full Name
UNION COUNT`i
CAPJPAJGN FINANIG
b. Mailing Address (include City, State, and Zip Code)
JUL 2 6 2021
c. Phone Number d. Email Address
b. Account Code e
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.
11,
Printed Nails of Treasurer Signature 45kppointed 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.
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Printed Name of Candidate Signature of Candidate Date
CRO -2100A NC state Hoard or &whom November 2019
NORTH CAROLINA
STATE BOARD OF ELECTIONS
Certification of Threshold
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)
RFCEJVFn
Treasurer Phone: 7l�y 7D J d X10. i
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 required 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 that have not been previously
reported from the beginning of the current election cycle. I further agree to file all future reports required.
Date Signed s'�..
CRO -3600 Certification of Threshold
vd NORTH CAROLINA
Mr -0 BOARD OF ELECTIONS
Confidential
FCertification 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:
Treasurer Name:
Treasurer Address:
(include city, state, & zip)
Treasurer Phone:
, Ak ?t?s
70Y 705- n<!a5-
e-(/
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.
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.
Type of aetount Financial Tncti ffi.n drlrlrc
By signing this statement, I authorize agents of the State Board of Elections to inspect all accoou= ED D
Date Signed Signature of Candidate or Tl Ereasures
For Candidate Committees Onlv
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 E�a L to inspect applicable accounts.
Date Signed Signature of Candidate or Treasurer
CRO -3500 Certification ofFinancialAccount Information
UNIU
CAMPAI
ae
Pa
N FINANCE
Jill6
2021
By signing this statement, I authorize agents of the State Board of Elections to inspect all accoou= ED D
Date Signed Signature of Candidate or Tl Ereasures
For Candidate Committees Onlv
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 E�a L to inspect applicable accounts.
Date Signed Signature of Candidate or Treasurer
CRO -3500 Certification ofFinancialAccount Information