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AmpKivient <br />Disclosure Report Cover Yes © No <br />Use this form for general report and committee information, must be signed and submitted along wither detailed forms. <br />Do not use this form to update information. <br />1. Committee information <br />Full Name <br />e- ID Number <br />C <br />L�Cjyk t J� L <br />+,r.1t �I�} �/}"� <br />�L�-i1�Lr�_ 7 U-VK cc"," <br />-.. <br />Mailbag Addrew (Jndude Ctly, S af3e aid Zip Code) <br />d. Date Filed <br />�v 19 nJ [. luom- DP_ at-r <br />' a 7 `�� <br />e. Pbmw Number <br />1r - 31s -7 <br />ReportYear <br />3. Period Start Date nmr 4. Period Et�d Date mm1 <br />5. Trewurer Full Name <br />Eel aoatw I C,6 qL L"� V kc <br />6. Type of Committee k one <br />9. Type of Eteport (check one type of report from one category) <br />® tV'anvtkwr Campatga ❑ Party <br />uldepal <br />yonly <br />`4.bt <br />Riffer lduin <br />❑ PAC ❑ Referendum <br />❑ organr--tional <br />❑ 0rgant7ational <br />❑ organizational <br />❑ independent Expendiwre ❑ Joint Fnndmiser <br />❑ Thirty -eve day <br />Qu-wrty <br />❑ Pre-referen&m <br />❑ Legal Expense Fund <br />❑ Pre-P.-.y <br />❑ Fust <br />❑ FRA <br />❑ Pre -election <br />❑ Pte- -ff <br />® Second <br />❑ Third <br />(3 Supplemental Final <br />❑ Annual <br />of Ij1Fid f►fupp&sable. cheak ,) <br />❑ Booster Fund - f <br />Semi-annual <br />❑ Fourth <br />❑ Special <br />❑ Building Fund <br />❑ Mid Year <br />Semi-annuai <br />❑ Year End <br />❑ Mid Year <br />10. Special Rgiog Name <br />❑ other. <br />❑ Final <br />❑ special <br />❑ Year End <br />❑ Final <br />13 special <br />. Number of Fundraisers this Report <br />_.._. <br />1L Account Information <br />II. Account Information <br />Fbww l Imli"un Full Name <br />a. Fuumcial Institution Full Name <br />f <br />RECEIVED <br />Prapoae <br />c. Aecomt Code <br />b. Purpose <br />Acta®t Cady <br />J- - - <br />AUG 0 5 292.6 <br />POW Rohm r <br />d. Period Begs Baf$noe <br />CABARRUS COUNTY <br />f <br />BOARD OF ELECTIONS <br />$ a �3 cl <br />$ <br />CERTIFICATION <br />I certify that the Cotntnium or Fund is in compliance with all applicable pmvis-ions of Article 22A, 22B & 22Q22M of Chapter 163 <br />of the NC General Statutes and dial no funds are contnungted with prohibited or other non -disclosed funds. I further certify that [his <br />report is complete, taste and correct and that I have been trained by the NC State Board of Elections. <br />a/J rJj 14. ajar.. d ara' <br />Priated Name of Signer Siof Appointed Treasurer Date <br />OR OFFICE USE ONLY <br />Date Received: Employee: Delivery <br />it <br />❑ Normall Mail <br />Mail <br />❑ Registered Mail <br />Date Postmarked: Employee: <br />® Hand Delivered <br />Date Scanned: ' 7 Employee: r" ❑ Electronically Fled <br />Date Data Entered: Employee: ❑ Signer has not received <br />mandato tramin <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 />M-646 0 NC State Board of Elections August 2008 <br />