Yanacsek, Robert_2021-CommitteeStatement of Organization - Candidate Committee Is this state9lent:
❑ New M 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 tip Code)
e. Date Organized
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c. Committee Website (Optional)
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L Phone Number
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2. Candidate Information
. Full Name
e. Party Affiliation
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. Mailing Address (mclude City, State, and Zip Code)
f. Office Sought
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c. Phone Number
d. Email Address
g. Next Election Year
1h. Jurisdiction
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Email copy of report notices
3. Treasurer Information
4. Assistant Treasurer Information
a. Full Name
a. Full Name
. Mailing Address (include City, Stste, and Zip Code)
b. MaBlug Address (include City, State and Zip Code)
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. Phone Number d. Email Address
c.
c. Phone Number
d. Email Address
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Send report notices by email Yes Q No
Email COPY of report notices
S. Custodian of Books Information (Keeper of Records
6. Account Information (inel. CRO -3500)
a. Full Name
a. Financial Institution Full Name
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b. Mailing Address (include City, State, and Zip Code)
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c. Phone Number
d. Email Address
b. Account Code
c. Type
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[IEmail copy of report notices
1 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.
Printed Name of Treasurer Signature of Appointed 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.
Printed Name of Candidate Signature of Candidate Date
CRO -2100A NC State Board of Elections November 2019
vo') NORTH CAROLINA
STATE BOARD OF ELECTIONS
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: ;2307? /-ate
Treasurer Name:
Treasurer Address:
(include city, state, & zip) A:r /L,
Treasurer Phone: 7,e 41 — 2 C I 4 ZZ Z
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.
By signing this statement, I authorize agents of the State Board of_FlecVons to inspec Iacc un gprovided.
"7 iz
Dae Signed Signature Candir surer "
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 Elections to inspect applicable accounts.
Date Signed
CRO -3500
Signature of Candidate or Treasurer
Certification of Financial Account Information
PTH CAR
STATE
ELECTI
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: lgO13j Q- SCo-r-1 yQ-,vQCS0K
Committee Name: M4V<
Treasurer Name: �XO sA:r CT Ste? T �ANAc-6 /9,e
If Candidate is own treasurer, designate an agent to carry out designations: PA l /,-
Ge �PGrlZ
Committee ID #:
Level Registered: [State] tGgIf county, specify: V
Y4,i.A-CS rhereby 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 Plan for Disbursement (eg. Amount or %)
(Seleet from §163-278.16B(a))
1.lOAAAA�6 soctfcry of 1-1-1c.c, co�i�r,tie /a�PV
2.
3.
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: e4-- e
Date: '71/2 /nce e
CRO -3900
Candidate Designation of Committee Funds