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Statement of Organization - Candidate Committee Is this statement: <br />New El 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 year. <br />1. Committee Information <br />a. Name or Committee <br />mmA4ee 4,o I�I <br />d. I Number <br />/ � d04 <br />b. Mailing Address (include City, State and Zip Code) <br />e. Date Organized <br />P. a fax -�d )- � <br />off- <br />. Committee Website (Optional) <br />VCandidate <br />f. Phone Number <br />Information <br />a. Full Name <br />� Wutr <br />e. Party Affiliation <br />—Doen c7Gr� _. <br />ress (include City, State, and 'Lip Code} <br />nx 86a <br />N G 2 �D)- <br />Pon <br />t'. Office Sought <br />��'� S L�ctrl rt,ni &�iDn <br />ber <br />_�40 <br />d. EmaiPAddress <br />- <br />g Next Election Yeariction <br />- ...... <br />a�a 41 <br />email copy of report notices <br />3. Treasurer Information <br />4. Assistant Treasurer Information <br />a. Full [tame <br />a. Full Name RECENED <br />j r <br />b. Mailing Address (inclujl e��,City, State, and Zip de) <br />1 � Alt (L I <br />b. Mailing Address (include City, State an e 202) <br />CASARRUS CouNTy <br />BOARD OF ELECTIONS <br />c. Phone Number <br />A. Email Address <br />c. Phone Number <br />d. Email Address <br />Send re art notices bye 1 0 Yes E3 No <br />D Email copy of report notices <br />5. Custodian of Books Information (Keeper of Records <br />6. Account Information (incl. CRo-3500) <br />a. Full Name _ 4Q� <br />^ <br />a. Financial Institution Full Name <br />b. Mailing Address (include City, State, and Zip Code) <br />aEa Z b <br />rn er <br />d. Email Address <br />NAccount Code <br />c. Type <br />�t"fJ�that <br />copy of report notices��16�1.� <br />rGeneral <br />the Committee is in compliance with all applicable provisions of Article 22A of Chapter 163 of the NC <br />Statutes and that no funds are commingled with prohibited or other non -disclosed funds. I further certify that <br />rt is complette,, true and correfctt..A�j� t—{ G [ t' ` 6 I -DV �'T"1 <br />Printed Name of Treasurer Signature of &inted Treasurer Date <br />I certify that the information above is correct, and I, as the candidate, appoint said treasurer to personally fulfill 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 />L I) G O Ct� u Sa ~r <br />inted Name of Candidate Signature ofCanciidate Date <br />C7:O-2100A NC State Board of Elections November ZU 19 <br />Y <br />MA <br />