Laserfiche WebLink
Amendment <br />Disclosure Report Cover Ur Yes o No <br />Use this forth for general report and committee information, must be signed and submitted along witfl other detailed forms. <br />Do not. use this form to undate information. <br />1. Committee Information <br />a. Full Name <br />c. ID Number <br />Commj�e e. -k ti[kt Gi id AuJo_ <br />l►V 7 <br />b. Mailing Address (include City, State and Zip Code) v <br />d. bate Filed <br />P. 01 &V 5" D <br />09 - 0 4 � .10y4 <br />�oNC.s7R D i� a S V"" -7-- <br />e. Phone Number <br />. Report Year <br />3. Period Start Date (mwddtyy) <br />4. Period End hate (mmlddlyy) <br />5. Treasurer Full Name <br />�+ <br />. Type of Committee (Check One) <br />4. Type of Report (check <br />onty one type of report <br />from one category) <br />Candidate Campaign ❑ Party <br />Municipal <br />StateJCannty <br />Referendum <br />❑ PAC ❑ Referendum <br />❑ Organizational <br />organizational <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 -runoff <br />Second <br />❑ nird <br />❑ Supplemental Final <br />❑ Annual <br />. Type of Fund (if applicable, check one) <br />❑ Boaster Fund <br />Sena -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 />Ajllmber of Fundraisers this Report <br />- <br />❑ Special <br />. Account Information <br />11. Account Information <br />a. Financial Institution Full Name <br />a. Financial Institution Full Name <br />u� if R - M?J <br />b. Purpose <br />c. Account Code <br />b. P-V."a_ R'�CEfVED _- -- <br />` <br />G Account Code <br />42mecug,o�1'nawee <br />- <br />IN -PERSON <br />w <br />d. Period Begin Balance <br />Period Begun Balance <br />U0 J 2026 _'d. <br />AUGr <br />CABARRIJS <br />CERTIFICATION TIQNS <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 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 />C Gy4t i-az&:!� S- <br />Printed Name of Signer Sigriature obkppointed Treasurer Date <br />OR OFFICE USE ONLY <br />Date Received. G Employee: Delivery Method <br />❑ Normal Mail <br />Date Postmarked: Employee: ❑ egistered Mail <br />and Delivered <br />j -2b j �ppj Electronically Filed <br />Date Scanned: Employee:[3 <br />er has not <br />Date Data Entered: Employee: Smanda or trannn ceived <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-210OA-E) to make committee changes. <br />CRO-I000 NC State Board of Elections August 2008 <br />