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Unendment <br />Disclosure Report Cover ❑ Yes 0 No <br />Use this form for general report and committee information, must be signed and submitted along with other detailed forms. <br />Do not use this form to update information <br />1. Committee Information <br />a. Full Name <br />c. ID Dumber <br />�G►rirn, we",�0 -BJr.t. avaS 1� <br />°(24W .T <br />b. Mailing Address (include City, State and Tap Code) <br />d. Date Filed <br />Crz� �� su' <br />di/31-210A4 <br />C.Ur,co,A_ N C ASty-a1 <br />e. Phone Number <br />9 "?c --5a 1 ,3 ; it <br />2. Report Year <br />3. Period Start Date (mm/dd/yy) <br />4. Period End Date 5. Treasurer Full Name <br />mm/dd/ V <br />AW3 <br />I:X f � ��a � � � r+ht�v- <br />6. Type of Committee Check One <br />9. Type <br />of Report (check only one type of re or2 rom one tale o <br />Candidate Campaigi ❑ Party <br />Municipal <br />state/county <br />Referendum <br />Organizational <br />Organiza4onal <br />Organizational <br />❑ PAC ❑ Referendum <br />Independent <br />Expenditure ElJoint Fundraiser <br />❑ <br />Thirty-five day <br />Quarterly <br />ElPre-referendumEl <br />❑ Legal Expense Fund <br />❑ <br />❑ <br />Pre-primary <br />Pre -election <br />❑ First <br />❑ Second <br />❑ Final <br />❑ Supplemental Final <br />7. Type of Fund (if applicable, check one) <br />❑ "Booster Fund" <br />❑ Building Fund <br />❑ <br />Pre -runoff <br />❑ Third <br />❑ Annual <br />Semi-annual <br />❑ Fourth <br />❑ Special <br />❑ <br />Mid Year <br />Semi-annual <br />❑ Other: <br />❑ <br />Year End <br />Cl Mid Year <br />10. Special Report Name <br />❑ <br />❑ <br />Final <br />Special <br />Year End <br />Final <br />❑ Special <br />S. Number of Fundraisers this Report <br />11. Account Information <br />11. Account Information <br />a. Financial Institution Full Name <br />a. Financial Institution Full Name <br />Stlrcz "�'�' <br />b. Purpose <br />C. Account Code <br />b. Purpose <br />c. Account Code <br />C. <br />. J--. <br />,q�qy- <br />d. Period Begin Balance <br />d. Period Begin Balance <br />$ <br />�x�cn IlTItYP� <br />CERTIFICATION <br />I certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 2213, & 22D-22M of Chapter 163 of <br />the NC General Statutes and that no funds are commingled with prohibited or other non -disclosed funds. <br />I further certify that this report <br />is complete, true and correct and that I have been trained by the NC toBoadons. <br />-_Lr� R• RY+ ,%kY IJL�,?/fZ <br />Printed Name of Signer <br />Signature of Appointed Treasurer <br />Date <br />FOR OMCE USE ONLY <br />� h � <br />Date Received: I L- <br />Delivery Method <br />Employee: <br />❑ Normal Marl <br />Date Postmarked: <br />_ <br />Employ jZ_ RECENED ❑ Registered Mail <br />I- F r6l Hand Delivered <br />Date Scanned: "�� <br />Emplo,yee.. h 4iR�1r ❑ Electronically Filed <br />F <br />JAN El <br />Signer has not received <br />mandatory training <br />Date Data Entered: <br />Employee: CPBARY <br />r-r-TIONS <br />Please Note: This form cannot be used to amend committee information such as the committee address, treasurer, assistant treasurer, <br />custodian of books information, oraccount information. <br />You must amend the Statement of Organization (CRO 2I OOA-E) to make committee changes. <br />CRO-I000 NC State Board of Elections August 2008 <br />