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Disclosure Report Cover ©e Y� °t 0 No <br />Use this form for general report and committee information, must be signed and submitted along with other detailed forms. <br />❑o not use this form to update information. <br />1. Committee Information <br />a. Full Name <br />c. ID Number <br />�ani� � F1,il+ R�rJ►,� <br />b. Mailing Address (include City, State and Zip Code) <br />d. Date Filed <br />431$ Er-1he W'Je b'_ <br />1111411 Z S <br />1,90'75 <br />e. Phone Number <br />Report Year 3. Period Start Date (nrnrlddlyy) 4. Period End Date (mtnlddlyy) <br />5. Treasurer Full Name <br />IZjrclj�_j <br />Owe i P-ieAN j- <br />Type of Committee (Check One) <br />Candidate Campaign ❑ Party <br />[6103PAC❑ Referendum <br />}. Ty pe of Report (check <br />Municipal <br />ElOrganizational <br />only one type of report <br />from one category) <br />IZcrerendum <br />❑ Organizational <br />State/County <br />WOrganizational <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 />❑ 1?re—election <br />❑ Pre -runoff <br />❑ second <br />❑ Third <br />❑ Supplemental Final <br />❑ Annual <br />7. 'f ype_of Fund_ (ojapplicahle, check une ) <br />❑ 13ooster 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 />❑ ()tilcr: <br />❑ Final <br />❑ special <br />❑ Year End <br />❑ Final <br />S. Number of Fundraisers this Report <br />❑ Special <br />11. Account Information <br />11. Account Information <br />Financial Institution Full Name <br />a. Financial Institution Full Natne <br />rti.w1i((n� <br />Purpose <br />c. Account Code <br />b. Purpose' IN -PERSON <br />c. Account Code <br />r• <br />l_G Afle- +LJ .n <br />J <br />'A <br />DEC 2 9 2025 <br />CASARRiIS COUNTY <br />BOARD OF ELECTIONS <br />d. Period Begin Balance <br />d. Period Begin Balance <br />$ � C <br />$ <br />CERTIFICATION <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 />4/,r5— <br />Printed Name of Signer Signature of Appointed Treasurer Date <br />FOR OFFICE USE oN>_,Y ja-lq PhN Relive Method <br />Date Received: ^ � S Employee: <br />❑ Normal Mail <br />Date Postmarked: Employee: ❑ Registered Mail <br />J [aHand Delivered <br />Date Scanned: + ' a Employee: PAN ❑ Electronically Filed <br />Date Data Entered: Employee: ❑ Signer has not received <br />mandatq trwnin <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-21a0A-E) to make committee changes. <br />CK61-I000 NC State Board of Elections August 2008 <br />