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Amendment <br />Disclosure Report Cover p Yes p No <br />Use this form for general report and committee information, must be signed and submitted along with other detai€Ncd forms. <br />T7n not nca chic fnrm to iznrlatr in£nrmg6nn <br />1. Committee Information <br />Full Nano <br />G ID Number <br />CQ i `ev <br />Mailing Address (include City, State and Zip Code) <br />d. Date Filed <br />SBao 1,vr C �tiR Eli r �jrlauh �� s l�lC <br />00V�c)�r. <br />c. Phl}`ot�q7�{ne Nuum}}ber <br />�n{�1 <br />CIVV _�-S 1V i <br />2. Report Year <br />3. Period Start_ Date (nurrtdd�yy) <br />4. Period End hate (mmldd1yy) <br />S. "Treasurer )Full Name <br />6. T e of Committee Check One) <br />9. Type of Report (check <br />only one i pe of report <br />from one category) <br />Candidate Campaign ❑ Party <br />Municipal <br />statelcounty <br />Referendum <br />❑ PAC ❑ Referendum <br />❑ Organizational <br />❑ Organizational <br />❑ Organizational <br />❑ lndependent Expenditure ❑ Joint Fundraiser <br />❑ Thirty-five day <br />Quarterly <br />Q Pre -referendum <br />© Legal Expense Fund <br />❑ Pre-primary <br />❑ First <br />❑ Final <br />❑ Preelection <br />❑ Pre -runoff <br />Semi-annual <br />❑ Second <br />❑ Third <br />❑ Fourth <br />❑ Supplemental Final <br />Q Annual <br />❑ Special <br />. Type of Fund (if applicable. check one) <br />Q Booster Fund <br />Q Building Fund <br />❑ Mid Year <br />Semi-annual <br />Year End <br />❑ Mid Year <br />10. Special Report Name <br />❑ 06Lcr: <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 />a. Financial Institution Full Name <br />a. Financial Institution Full Name <br />CEIVED - <br />Ili!-PER501V <br />b. Purpose <br />e. Account Code <br />b. Purpose <br />G Account Code <br />�0.i. �. <br />VJ-Ya <br />Q <br />OU <br />CABARR ELECT! <br />BOARD OF ELI= <br />d. Period Begin Balance <br />rlod Begin Balance <br />$ 24 - <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 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 andf{ that I have been trained by the Ne StatmBoard of Elections. <br />Printed Name of Signer i nature of ointed Treasurer Date <br />FOR OFFICE USE ONLY <br />I 1 Delivery Method <br />Date Received: I�I� Employee: <br />❑ Normal Mail <br />❑ Registered Mail <br />Date Postmarked: Employee: <br />rand Delivered <br />Pori <br />I - a 2 _ 2 t Pori ❑ Electronically Filed <br />Date Scanned: 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 (CRC)-210OA-E] to make committee changes. <br />C'RO-1000 NC State Board of Elections August Zlltlx <br />