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Report Cover <br />Disclosure Re <br />P 0 7•rs o No <br />Use this form for general report and committee information, must be signed and submitted along wiiIt 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 />b. Mailing Address (Include City, State and Zip Code) <br />d. Date Filed <br />t9 K rJA,JJ,'k- OAo- P A ~r z_3 <br />'L�p BCr� <br />r•}r-0 -­0� <br />I ZG ?_0ii <br />e. Phone Number <br />9 pa. S—X t-I I LG <br />2. Repd . :. Period Start Date {mrttlddt .s <br />- <br />.1-�=-s�tgav <br />tdtj <br />j�arfy 7�n.+ jL,ti4- <br />6. of Commmttee Check One <br />9. Type <br />of Report (check only one type of report from one category) <br />Candidate Campaign ❑ Party <br />Municipal <br />State/County <br />Referendum <br />❑ PAC ❑ Referendum <br />❑ Organizational <br />Organizational <br />❑ Organizational <br />❑ [ndependent Expenditure ❑ Joint Fundraiser <br />❑ Tl hirty-five day <br />Quarterly <br />❑ Pre -referendum <br />❑ Legal Expense Fund <br />❑ Pre-primary <br />❑ First <br />❑ Final <br />❑ Pre -election <br />❑ 1're-runoff <br />Semi-annual <br />❑ Second <br />❑ Third <br />❑ Fourth <br />❑ Supplemental Final <br />❑ Annual <br />❑ Special <br />. Type of Fund (?I'appdicable, check one) <br />❑ Booster Fund <br />❑ Building Fund <br />❑ Mid Year <br />Semi-annual <br />❑ Year End <br />[:I Mid Year <br />10. Special Report Name <br />❑ Other: <br />❑ Final <br />❑ Special <br />❑ Year find <br />❑ Final <br />11 Special <br />8. Number of Fundraisers this Report <br />11. Account Information <br />11. Account Information <br />a. Financial Institution Full Name <br />a. Financial Institution Full Name <br />b. Purpose <br />c. Account Code <br />b. Purpose <br />c. Account Code <br />REeENED <br />1 PERSON <br />DEC 2 9 2025 <br />d. Period Begin Balance <br />d. Period Begin Balance <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 or other non -disclosed funds. I further certify that this <br />rcport is complete, true and correct and that I have been trained by the NC State Board of Elections. <br />Printed Name of Signer iLature of Appointed Treasurer bate <br />FOR OFFICE USE ONLY <br />Date Received: �°Employee: PAW Delivery Method <br />❑ Normal Mail <br />Date Postmarked: Employee: ❑ Registered Mail <br />® Hand Delivered <br />Date Scanned: a ° Employee: ❑ Electronically Filed <br />0 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-210OA-E) to make committee changes. <br />CCU-1000 NC State Board of Elections August 200 <br />