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Amendment <br />D' 1 1R rt � <br />1SC quSLII'u %;F" UVVr l] Yes E3 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 1-0rm io 11nijatr-, information. <br />1. Committee Information <br />Full <br />c. ID Number <br />Name <br />1.� , ��� i� Cl 1 i71 ii I � y <br />Mailing Address (include City, State and Zip Code) <br />d. Date Filed <br />0 a..�¢ alb <br />_ <br />S$�a %Vw w �a —(V; ►� � I�do f �f sr, -, C 2 i �� <br />e. Phone Number <br />2. Report Year <br />3. Period Start Date (mmlddl ) 14. Period End Date (nnnladl ) <br />5. Treasurer Full Name <br />6. e of Committee Check One) <br />Candidate <br />9. Type of Report (check <br />only one type of report <br />from one category) <br />Campaign Q Party <br />Municipal <br />State/County <br />Referendum <br />❑ PAC ❑ Referendum <br />❑ Qrganizational <br />❑ Organizational <br />❑ Organizational <br />❑ Independent Expenditure ❑ Joint Fundraiser- <br />❑ Thirty-five day <br />Quarterly <br />❑ Pre -referendum <br />❑ Legal Expense Fund <br />0'Pre-primary <br />[Er First <br />Final <br />❑ Pre -election <br />❑ Pre -runoff <br />❑ Second <br />❑ Third <br />Supplemental Final <br />❑ .knnual <br />. Type of F_tmd Wapplicable, check raze, <br />❑ Booster Fund <br />Semi-annual <br />❑ Fourth <br />❑ Special <br />❑ Building Fund <br />❑ Mid Year <br />Semi-annual <br />❑ Year End <br />❑ Mid Year <br />14). Special Report Name <br />El {ltl, r <br />❑ Final <br />❑ Special <br />❑ Year End <br />❑ Final <br />8. Number of Fundraisers this Report <br />❑ 5lxrial <br />11. Account Information <br />11. Account Information <br />. Financial Institution Full Name <br />a. Financial Institution Full Name <br />h. Purpose <br />c. Account Code <br />h. Purpose IN-PFRS <br />c. Account Code <br />(d i Fl <br />d. Period Begin Balance <br />d. Period Begin Balance <br />` <br />$ <br />BD ❑F F Culps <br />hi <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 o er non -disclosed funds. I further certify that this <br />report is complete, true and correct and that I have been trained by the N t and of Elections. <br />Pa\�'-Cy_ L6ASew 0:;Alf� <br />Printed Name of Si ner t ature of 4rppointed Treasurer Date <br />OR OFFICE USE ONLY <br />Date Received: Employee: ��L[ _ Delivery Method <br />❑ Normal Mail <br />Date Postmarked: Employee: ❑ Registered Mail <br />and Delivered <br />�' WAN ❑ Electronically Filed <br />Date Scanned: Employee: <br />❑ Signer has not received <br />Date Data Entered: Employee: mandatory tmnin <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 2rganization (CRO-210DA-E) to make committee changes. <br />('K -1 you NC State Board of Elections August 2008 <br />