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Statement of Organization - Candidate Committee is this statement, <br />❑ New ❑ Amended <br />Use this form to create a new or update an existing candidate committee. <br />This form must be accompanied by form CRO-3500. An amended form is required for each new election vear- <br />I. Committee Information <br />a. Name oYCommittee <br />d, ID Number <br />�/j� <br />eu- <br />,{ { <br />S l 1 . YI'!� } •{ � <br />b. Mailing Address (include City, State and Zip Code) <br />e. hate Organized <br />c. Committee Website (Optional) <br />Phone Number <br />If. <br />2. Candidate Information <br />a. Full Name <br />- <br />c. Party Affiliation <br />A <br />Y �1 I t l•1 <br />b. Mailing Address (include City, State, and Zip Code) <br />L Office Sought <br />e . Phone Number <br />d. Email Address <br />g. Next Election Year <br />h. Jurisdiction <br />I GZ rrUS <br />�DV <br />Wi LL.r'Am5_1 <br />511,'I • <br />❑ Email copy of report notices <br />3. Treasurer Information <br />4. Assistant Treasurer information <br />a. Full Name <br />a. Full Name <br />b. ,Mailing Address (include City, State, and Zip Code) <br />b. Mailing Address (include City, State and Zip Code) <br />R C VEVED <br />IN -PERSON <br />c. Phone Number <br />d. Email Address <br />c. Phone Number <br />d. Email Address < <br />I �i�Liams <br />rytc+l•�c <br />CASARRUS COUNTY <br />Send report notices bv email Lj Yes <br />Lj No <br />LJ Email copy of re art notices <br />5. Custodian of Books Information (Keeper of Records <br />6. Account information (fnct. CRO-3500) <br />a. Full Name <br />a. Financial Institution Full Name <br />[!� S <br />b. Mailing Address (include City, State, and Zip Code) <br />c. Phone Number <br />d. Email Address <br />b. Account Code <br />c. Type <br />❑ Email copy of report notices <br />I certify that the Committee is in compliance with all applicable provisions of Article 22A of Chapter I63 of the NC <br />General Statutes and that no funds are commingled with prohibited or other non -disclosed funds. I further certify that <br />this report is complete, true and correct. <br />S <br />2Z <br />Printed Name of Treasurer <br />signature of Appointed Treasurer hate <br />I certify that the information above is correct, and <br />1, as the candidate, appoint said treasurer to personally fulfili the <br />duties and responsibilities imposed upon the appointed treasurer and subject to the penalties in Article 22A of Chapter <br />163 of the NC General Statutes. <br />Printed Name of Candidate <br />Signature of Candidate Da c <br />LHU-21WA NC State Board of Elections November 2019 <br />