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Amendment <br />Disclosure Report Cover ❑ 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 tine this form to rrndate informwinn- <br />1. Committee Information <br />Full Name <br />c. ID Number <br />57 <br />Mailing Address (include City, State and Zip Code) <br />d. Date Filed <br />7 f t <br />3 g G 7 cc -.5 •, <br />e ,-? yy rd ej Y2_Pj , tJG �1�, tS J <br />e. Phone Number <br />. Report Year <br />3, Period Start Date (mud ) <br />4. Period End Date mmld } 5. Treasurer Fyil Name <br />(-,3a a r- A �'r � <br />,702,S <br />rs- x�_ <br />6. Type of Committee Check One <br />9. Type of Re rt (check <br />Municipal <br />only one type of report <br />State/County <br />from one category) <br />❑ Candidate Campaign ❑ Party <br />Referendum <br />❑ PAC ❑ Referendum <br />❑ Organizational <br />❑ Organizational <br />❑ Organizational <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 />❑ Pre -election <br />❑ Pre -runoff <br />Semi-annual <br />❑ Second <br />❑ Third <br />❑ Fourth <br />❑ Supplemental Final <br />❑ Annual <br />❑ Special <br />7. Type of Fund fif applicable, check one) <br />❑ Booster Fund <br />❑ Building Fund <br />❑ Mid Year <br />Semi-annual <br />❑ Year End <br />❑ Mid Year <br />10. Special Report Name <br />❑ Other: <br />❑ Final <br />❑ Special <br />❑ Year End <br />❑ Final <br />8. 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 Name <br />. Purpose <br />c. Account Code <br />b. Purpow IN-FERr YN <br />count Code <br />JUL Q 1 2026 <br />d. Period Begin Balance <br />l eriad Begin Balance <br />CABAR4 ' js COUNTY <br />BOARD OF ELECTION <br />1 <br />v *1 <br />$ L 5L$" <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 State Board of Elections. <br />-NC <br />k4'//" r-- /Y",-��- <br />Printed Name of Signer Sfgnature of Appointed Treasurer Date <br />FOR OFFICE USE ONLY <br />r <br />�� { • (� FAA N Delivery <br />� <br />-Method <br />Date Received: Employee: <br />Normal Mail <br />❑ Registered Mail <br />Date Postmarked: Employee: <br />® Hand Delivered <br />7-1-IC WA Al ❑ EIectronically Filed <br />Date Scanned: Employee: <br />❑ Signer has not received <br />Date Data Entered: Employee: mandatory trainin <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-2100A-E) to make committee changes. <br />CRO-I000 NC State Board of Elections August 2008 <br />