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Amendment <br />Disclosure Report Cover p Yes o 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. ID Number <br />pp �y <br />0 <br />y <br />1 L I 1} 1 <br />b. Mailing Address (include City, State and Zip Code) <br />d. Date Filed <br />c5oi-A -B�A-crn w-�- Or <br />e. Phone Number <br />� 4 � � <br />ex. 4 � i�3 l <br />2. Report Year <br />3. Period Start Date.(mmlddlyy) <br />4. PeriodEnd Date jmmlddlyy) <br />5. Treasurer Full Name <br />20 z_('- <br />6 <br />©Q ��1 s <br />��C 1 !l r_�iLr <br />6. T e of Committee Check One <br />4. Type <br />of Report (check only one type of report from one category) <br />LT Candidate Campaign ❑ Party <br />Municipal <br />State) ounty <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 />Second <br />❑ Third <br />❑ Supplemental Final <br />❑ Annual <br />7. 'I�pe of Fund (if applicable, check one) <br />Boostcr Fund <br />Semi-annual <br />❑ Fowth <br />❑ Special <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 />f--- <br />- -� - -- _ <br />❑Special <br />11. Account Information <br />11. Account Information <br />a. Financial Institution Full Name <br />a. Financial Institution Full Name <br />r 'S <br />RLCEiVED <br />h. Purpose <br />c. Account Code <br />h. Purposec. <br />Account Code <br />Cotn�&ox <br />NkAj <br />d. Period Begin Balance <br />--- - <br />d. Period Begin Balance <br />CABARRUS COUNTY <br />BOARD OF EtiMCTION <br />T k <br />$ <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 Genera] 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 NC State Board of Elections. <br />�I v2k 1-5 <br />S jIl UU CcI4� .� <br />Printed Name ol'Si =ner Signature of'Appointed Treasurer Date <br />FOR OFFICE USE ONLY g } <br />� Delivery Method <br />Date Received: Employee: <br />❑ Normal Mail <br />❑ Registered Mail <br />Date Postmarked: Employee: <br />Hand Delivered <br />�a �tp ❑ Electronically Filed <br />Date Scanned:6 Employee: <br />❑ Signer has not received <br />Date Data Entered: Employee: mandatory training <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 />