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Disclosure Report Cover �IAmeudment <br />Yes ❑ No <br />Use this form for general report and committee information, must be signed and submitted along with other detailed forms. <br />Do riot iice this form to update information. <br />1. Conunittee Information <br />a. Full Name <br />c. ID Dumber <br />0 F, <br />h. Mailing Address (include City, State and Zip Code) <br />d. Date Filed <br />j04�ZZb z'S <br />j gy►'lc v`7� �— S c.� <br />0tu " ! 1 <br />a Phone Number <br />2. Report Year <br />3. Period Start Date (nunIdd/Fy) <br />4. Period End Date (mndddl ) <br />5. Treasurer Full Name <br />�T <br />1 Cy 'I} l tvi 's eL. h Al V <br />�I - I � � <br />Z' Z � Z 7 <br />6. Type of CotmnAttee (Check One) <br />9. Type of Report (check <br />only one type of r port <br />from one category) <br />statelCounty <br />Referendum <br />Candidate Campaign ❑ Party <br />Municipal <br />❑ PAC ❑ Referendum <br />1 Organizational <br />T Organizatianal <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 />. 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 lnstitudon Pull Name <br />a. Financial Institution Full Name <br />RtvWA <br />RECENED <br />. Purpose <br />c. Account Code <br />b. Purpose <br />c. Account Code <br />07V'W m �-t <br />DEC 2 2 2025 <br />CABARRIIS COUNTY <br />BOARD Or F_!LECTIONS <br />d. Period Begin Balance <br />d. Period Begin Balance <br />$ <br />CERTIFICATION <br />I certify that the Commit tee 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 NC State Board of Elections. <br />W,46e.A�XJ IC J <br />Printed Name of Signer &en pfre of A pp o surer Date <br />OR OFFICE USE ONLY <br />Date Received: � � � a _ � � Employee: Delivery Method <br />❑ Normal Mail <br />Date Postmarked: Employee: ❑ Registered Mail <br />II [� Hand Delivered <br />Date Scanned: 3� Employee: ❑ Electronically Filed <br />❑ Signer has not received <br />Date Data Entered: Employee: mandato 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-21 OOA-E) to make committee changes. <br />LRO-1000 NC State Board of Elections August 2009 <br />