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Statement of Organization - Candidate Committee Is this state nt: <br />❑ New Amended <br />Use this form to create a new or update an existing candidate committee. <br />This form must be accomuanied by form CRO-3500. An amended form is required for each new election year. <br />1. Committee Information <br />a. Name of Committee <br />d. ID Number <br />h. Mailing Address (include City, State and Zip Code) <br />e. Date Organized <br />{ I '1 3, •4-1n r ,a,� can . i'� rs . ,._I , <br />r <br />l{ Z4 �}2e <br />C� a '-.3 'Lc� a C Low <br />c. Committee Webs l#e (Optional) <br />f. PhoA Number <br />Z. Candidate Information <br />Full Name <br />e. Party Affiliation <br />Mailing Address (include City, State, and Zip Code) <br />f. Office Sought <br />[G].S C,j I-,,, ! <br />Phone Number <br />d. Email Address <br />g. Nexrt� Election Year <br />h. Jurisdiction <br />n <br />i li0 a J_[ L( <br />it- 4.&K i c� LCA elm L-w 1L,75 <br />Y►�d"�r <br />(' q f��lL�' �: Cci . +: <br />,'s <br />[7 Finail copy of re ort notices <br />a <br />3. Treasurer Information <br />4. Assistant Treasurer Information <br />a. Full tame <br />a. Full Name <br />4)A <br />b. Mailing Affiress (include 09, State, and Zip Code) <br />b. Mailing Address (include City, St MEEode) <br />IN-IE.R ON <br />6-ill <br />JAN 9 5 2026 <br />Phone Number <br />d. Email Address <br />c- Phone Number <br />d. Email A ss <br />APANRUS COUNTY <br />0-14 RG vkfe5o <br />BOARD OF ELECTIONS <br />Send report notices b • email KgTes <br />No <br />Email copy of report notices <br />. Custodian of Books Information (Keel2er of Records <br />6. Account Information (invl. CRO-3500) <br />Full Name <br />a. Financial Institution Full Name <br />Mailing Address (include City, State, and Zip Code) <br />}� <br />l <br />Phone Number <br />d. Email Address <br />b. Account Code <br />e. Type <br />❑ EmaiI copy of report notices <br />I certify that the Committee is in compliance with all applicable provisions of Article 22A of Chapter 163 of the NC <br />General Statutes and that no funds are commingled with prohibited or other non -disclosed funds. l further certify that <br />this report is complete, true and correct. <br />V. <br />f 1 kbok <br />Print Name of Trerer <br />Signatur A of ed T asurer Date <br />71 <br />I certify that the 'information above is correct, and 1, as the candidate, appoint said treasurer to personally fulfill the <br />1163 <br />duties and responsibilities imposed upon the appointed treasurer and subject to the penalties in Article 22A of Chapter <br />of the NC General Statutes. <br />14kM L <br />�y <br />�s;r �C { 14-1za Z� <br />Printed Name of Candidate <br />Aignature of Candidate Date <br />CRO-2100A NC State Board of Elections November 2019 <br />