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Amendment <br />Disclosure R t C <br />epor oVelr 13 Yes ❑ 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. Conunittee Information <br />a. Full Name <br />c. ID Number <br />Iq� P�k-Tsu�k Flirt` �+°�-S <br />b. Mailing Address (include City, State and Zip Code) <br />d. Date Filed <br />e. Phone Number <br />Y160 • aS$ • 5k z� <br />2. Heport Year <br />3. Period. -Start Date (nntmlddlyy) <br />- - -- <br />4. Period End Date (mnvddlyy) <br />- - <br />5. Treasurer Full Name <br />-- — - - <br />Z��S <br />i2_ f(rz❑z..s <br />tzlll�25 <br />j h^� f A° Tpnc-K <br />6.f- <br />Type of Committee (Check One) <br />4. Type of Report {check only one type of report from one category) <br />❑ Candidate Campaign ❑ Party <br />❑ PAC ❑ Referendum <br />Cj Independent Expenditure ❑ joint Fundraiser <br />❑ Legal Expense Fund <br />Municipal <br />❑ Organizational <br />❑ 'rhirty-five day <br />❑ Pre-primary <br />State/County _ <br />WOrganizational <br />Quarterly <br />❑ First <br />Referendum <br />❑ Organizational <br />❑ Pre -referendum <br />❑ Final <br />Pre -election <br />❑ Pre -runoff <br />Semi-annual <br />❑ Mid Year <br />❑ second <br />❑ Third <br />❑ Fourth <br />Semi-annual <br />❑ Supplemental Final <br />❑ Annual <br />❑ Special <br />7, Type of Fund (if applicable, check one) <br />❑ Booster Fund <br />❑ Building Fund <br />[� Other: <br />❑ Year End <br />❑ Final <br />❑ Special <br />❑ Mid Year <br />❑ Year End <br />❑ Final <br />10. _Special Report Name <br />8. Number of Fundraisers this Report <br />--- - •-- -- <br />El Special <br />11. Account Information <br />11. Account Information <br />a. Financial Institution Full Name <br />a. Financial Institution Full Name <br />MCErVED <br />b. Purpose <br />c. Account Code <br />vmt <br />b. Purpose <br />e. Account Code <br />CABARRUS CO <br />BOARD OF Et-E <br />d. Period Begin Balance <br />&Mod Begin Balance <br />CERTIFICATION <br />I certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 2 2 B & 22D-22M of Chapter I63 <br />of the NC General Statutes and that no Funds are commingled with prohibited or other non -disclosed funds. I further certify that this <br />report is complete, true and correct and that I have been trained by the NC State Board of Elections. <br />JAW r r I <br />Printed Name of Si ner Si nature ❑ pointed Treasurer ate <br />FOR QFFICE USE ONLY <br />Date Received: '' Employee: �H Delivery Method <br />❑ Normal Mail <br />❑ Date Postmarked: Employee: Registered MailHand Delivered <br />Date Scanned: a la 3 Employee: PAN ❑ Electronically Filed <br />Date Data Entered: Employee: ❑ Signer has not received <br />mandato training <br />Please Note: This form cannot be used to amend committee information such as the committee address, treasurer, <br />assistant treasurer, custodian of books information, or account information. <br />You must amend the Statement of Organization (CRO-2I OOA-E) to make committee changes. <br />LIEU-1 UUU NC State Board of Elections August 2008 <br />