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Statement of Organization - Candidate Committee Is this statement: <br />❑ 1Vew © Amended <br />Use this form to create a new or update an existing candidate committee. <br />Phis form must be accompanied by form CRO-3500. An amended form is required for each new election year. <br />Committee Information <br />a. Name of Committee <br />d. ID Number <br />b. MailingAddress (include CS , State and Zip Code) <br />e. Date Organized <br />11. <br />3 q L, 7 CAS f/&/Y L VJ .0'/I f� ��c c, etL) NA, ��sj <br />f; -/s' J'3' <br />Committee Website (Optiona)) <br />f. Phone Number <br />2. Candidate Information <br />a. Full Name <br />e. Paro. Affiliation <br />]Mailing Address (include City, State, and Zip Code) <br />f. Office Sought <br />34 4,7 it 3 44 w y && i .2P /1 <br />d <br />�a ti�b R L a 2Jf <br />e <br />Ip <br />c . Phone Number <br />d. Email Address <br />g. Next Election Year <br />h. Jurisdiction <br />grto-;L3L Sass <br />,�1+ 0, (1 kr4ev 6Cn4l , <br />',j,.ko <br />I <br />", "/. <br />L",C-1c� 'VT <br />ll Email copy of report notices <br />3. Treasurer Information <br />4. Assistant Treasurer information <br />a. Full Name <br />a. Full Name <br />r <br />rtJ'r I ItA. ► G a rS�r_ <br />b. Mailing Address (include City, State, and Zip Code) <br />b. Mailing Address (include City, State and Tip Code) <br />_ tg4,7 -AP P 7 <br />�►v . ,X -D J <br />C. Phone Number <br />d. Email Address <br />c. Phone Number <br />d. Email Address <br />all <br />Send report notices by email Yes No <br />Email co of re ort notices <br />5. Custodian of Books Information (Keeper of Records <br />6. Account Information (ine!. CRO-3500) <br />a. Full Name <br />REQEDMO <br />a. Financial Institution Full Name <br />b. Nlailing Address (include ity, StateJihRRF03 rfe) <br />DEC 2 2 2025 <br />c. Phone Number <br />d. Email tri &hRRUS COUNTY <br />b. Account Code <br />c. Type <br />e-b iEe�kif-i <br />❑ Email copy of report notices <br />I certify that the Committee is in compliance with all applicable provisions of Article 22A of Chapter 163 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 />Printed Name of Treasurer'Signature of Appointed 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 />Wr/f4"4, /Lsza'�-Z C� ��--t-k-.2;Z . 7— <br />Printed Name of Candidate Signature of Candidate Date <br />t KU-21 UUA NC State Board of Elections November 2019 <br />