Laserfiche WebLink
Disclosure Report Cover <br />Aam. z,tment <br />❑ Yes ❑ No <br />Use this form for general report and committee information, must be signed and submitted along with other detailed forms. <br />Do not use this form to update information <br />1. Committee Information <br />a- Full Name <br />c. W Number <br />C m I ll l �� �o c ��; r �1� •v <br />b. Mailing Address (include City, State and Zip Code) <br />d. Date Filled <br />----- <br />516' C'LA1Ac� 17��-Pp- sc,,, <br />/ -:�00 <br />) <br />s� ❑� C: UIZC{ I [� �— <br />c. <br />_eNumber <br />2. Report Year 3. Period Start Date (mmlddhy) <br />4. Period End Date <br />S. Treasurer Full Name <br />[ennJdd�YY <br />rr` /q r �[ <br />�/✓ �i7 ♦ LJ "' <br />6. Type of Committee Check One <br />9. Type of Report check om! one 4pe re rt om one ealegaryf <br />Rr Candidate Campaign ❑ Party <br />Municipal State/County <br />Referendum <br />❑ PAC: ❑ Referendum <br />❑ Organizational <br />❑ thganiaational <br />n (hganirational <br />Independent ❑ Joint Fundraiser <br />Expenditure <br />❑ Thirty-five day <br />Quarterly <br />El Pre -referendum. -Pre -referendum.❑ <br />❑ Legal TixNnse Fund <br />9. Tyw V1 a ucEai ; up.f.i­k, cAwci once] <br />❑ f if-j+Fia ry <br />❑ Pre -election <br />❑ Fiist <br />❑ Second <br />❑ Final i <br />❑ Supplemental Final <br />❑ "Booster Fund" <br />❑ 13uilding Fund <br />❑ Pre-nnnoff <br />❑ Third <br />❑ Annual <br />Semi-annual <br />❑ Fourth <br />❑ Special <br />❑ Mid Year <br />Sena -annual <br />❑ Other7 <br />❑ Year FP.d <br />❑ Mid Year <br />10. special Reeort NIT." <br />❑ Fa. —I <br />❑ Special <br />Year Ead <br />❑ Final <br />❑ Special <br />8. Number of Fundraisers this Report <br />11. Account Information <br />11. Account Information <br />a. F'unancialInstitution FultName <br />a_ Financial Institution Full Ntmc <br />b. Purpose c. Account Code <br />b. Purpose c. Account Code <br />dRecf.yN� <br />_Fk <br />d. Period Begirt Balance <br />d. Period Begin Balance <br />' """w,rr <br />$ V <br />$ <br />CERTIFICATION <br />1 certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 22B, & 22D-22M of Chapter 163 of <br />the NC General Statutes and that no funds are commingled with prohibited or other non -disclosed funds- I further certify that this report <br />is complete, true correct and that I have been trained by the NC State Board of Elections. <br />fA� <br />:inte<.Id v der .S':&i=e of AppoinfedTreasttrer L'aL <br />FOR OFFICE USE ONLY <br />Date Received: i �` Employev Delivery Method <br />❑ Normal Mail <br />Date Postmarked: Employee ❑ Registered Mai <br />a� jrfr Hand Delivered <br />` >;mpioyee: Whlf ❑ Electronically Filed <br />irate Scanned: !`u` <br />❑ Signer has not received <br />mandatory training <br />Date Data Entered: Employee: <br />Please Note: This form cannot be used to amend committee information such as the committee address, treasurer, usurer, <br />custodian of books information, or account information. <br />You must amend the Statement of Organization (CRO-2l00A-E to make committee char es1AN 3 0 202 <br />CRO-1000 NC State Board of Elections CABARRLIS CO��Y2008 <br />BOARD OF ELECTIONS <br />