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Amendment <br />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 undatC infonrtalion. <br />1. Committee Information <br />a. Fula Name <br />c. Ill Number <br />IWl 'LA ,Jexi/ f at <br />b. Mailing Address (include City, State and Zip Code) <br />d. Bate Filed <br />Glecv�-Nt(k �Jj IVOM4 P1'U5a4/VL- (2 012-4 <br />0 ZL,'?� <br />e. Phone Number <br />I�s2 <br />. Re ort Year <br />3, Period Start Date (mmlddl )4. Period End Date immtddl ) <br />5. Treasurer Full Name <br />30 4 <br />r i�C i <br />. T pe of Committee [Check Qqc� _ <br />Type of Report (check <br />only one type of report <br />from one category) — <br />Can didnic C'aFnpaign ❑ Party <br />unicipal <br />StateXounty <br />Referendum <br />❑ PAC ❑ Refemuclum <br />organizational <br />fEE3 <br />❑ OrganiWional <br />❑Organizational <br />❑ Independent Expenditure ❑ Joint Fundraiser <br />Thirty-five day <br />Quarterly <br />❑ Pre -referendum <br />❑ Legal Expense Fund <br />Pre-primary <br />❑ First <br />❑ Final <br />Pre -election <br />❑Pre-rungff <br />Second <br />❑ Third <br />❑ Supplemental Final <br />❑Annual <br />. T of Iirnd flfapplicabte, checkanej <br />❑ Booster Fund <br />Semi-annual <br />❑ Fourth <br />❑ Special <br />❑ Building Fund <br />❑ Mid Year <br />Semi-annual <br />❑ Year End <br />❑ Mid Year <br />10. Special Report Name <br />❑ Other: <br />❑ Final <br />❑ special <br />❑ Year End <br />❑Final <br />S. Natmber of Fundraisers this Report <br />❑ Special <br />11. Account Information <br />11. Account Information <br />a. Financial Institution Full Name <br />a. Financial Institution Null Name <br />b. Purpose <br />c. Account Code <br />b. Purpose <br />-- <br />RL'CEIVED <br />e. Account Code <br />_^ <br />IN -PERSON <br />GC>v C1\ <br />JUL Q 7 2026 <br />d. Period Begin Baianre <br />d' Period Begin Balance <br />.J <br />4 + <br />$ <br />CERTIFICATION BOARD OF ELECTIONS <br />I certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 22B & 22D-22M of Chapter 163 <br />of the NC General Statutes and that no funds are commingled with prohibited er non -disclosed funds. I further certify that this <br />report is complete, true and correct and that I have been trained by the t and of Elections. <br />Printed Name of Signer i nature of Appointed rreasui)Lr Date <br />FOR OFFICE USE ONLY 7 <br />r ' '�� <br />Date Received: Employee: Delivery Method <br />❑ Normal Mail <br />Datc Postmarked: Employee: ❑ Registered Mail <br />® Hand Delivered <br />�^ <br />Date Scanned: d Employee: ❑ Electronically Filed <br />© Signer has not received <br />Date Data Entered: Employee: mandatory 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-210dA-E) to make committee changes. <br />CKO -1 tHIU NU State Hoard of Elections August 2008 <br />