Bright Organizational Information & Certification of Inactive Status F---I
A-A,
,Amendment
Statement of Organization - Candidate Committee OYes 0No
Use this form to create a new or update an existing candidate committee.
This form must be accompanied bv forms CRO-3 100 and CRO-3500.
Committee Information
Full Name c.ID Number
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b.Mailing Address(include City,State and Zip Code) d.Date Organized
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e.Phone Number
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2.Candidate Information LJ Candidate's Primary Committee
a.Full Name c.Candidate ID Number d.Party Affiliation
b:Mailing Address(include City,State,and Zip Code) e.Office Sought f.Jurisdiction
11
CYC NC �6LA (If office sought is nonpartisan, write "Nonpartisan"in[d]
Party Affiliation.)
I'Treasurer Information 4.Custodian of Books Information
a.Full Name a.Full Name
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b.Mailing Address(include City,State,and Zip Code) b.Mailing Address(include City,State,add,Ztp Cod6) ?010
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NHC Bd of Elections
c.Phone Number d.Email Address c.Phone Number d.Email Address
5.Assistant Treasurer Information L] Add 6.Account Information (in j Ad
a.Full Name ❑ Remove a.Financial Institution Full Name ❑ Remo
b.Mailing Address(include City,State,and Zip Code) 1).Purpose
c.Phone Number d.Email Address c.Account Code d.Type
I
CERTIFICATION
I certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A,22B &22D-22M of
Chapter 163 of the NC General Statutes and that no funds are commingled with.prohibited or other non-disclosed funds. I
further certify that this report is complete,true
Printed Name of Signer Signature of Appointed Treasurer Dat�
CRO-2100A NC State Board of Elections December 2007
RECEIVED
North Carolina FEB 0 8 2010
State Board of Elections NHC 6d of Elections
506 N Harrington Street
Raleigh,NC 27603
Kimberly Westbrook-Strach Mailing Address
Deputy Director—Campaign Reporting PO Box 27255
Raleigh,NC 27611-7255
(919) 733-7173
Fax: (919) 715-8047
Certification of Treasurer
This Certification is used by Candidate Committees to appoint a treasurer to the committee.This form is
required and must accompany the Candidate's Statement of Organization
FILED BY:
Candidate Name: [...O\ i Q n q �' (1 P✓5 cj h�
Treasurer Name: �C�\ki r 5
Treasurer Address: L-A O 1 b
(include city, state,&zip) Z)QJ—
Treasurer Phone: C) — act q
I certify that the above information is correct,and I,as candidate,appoint said treasurer to personally fulfill
the duties and responsibilities imposed upon the appointed treasurer and subject to the penalties and
sanctions in Subchapter VIII.Regulation of Election Campaigns of Chapter 163 of the North Carolina
General Statutes.
I understand that if the above Treasurer changes,it will be necessary to certify a new treasurer and amend
the existing Statement of Organization within 10 days of the vacancy.I further understand that the above
Treasurer is required to receive training by the State Board of Elections within three months of this
appointment according to Article 163.2789(k).
Date Signed Signature of Candidate
Note:This Certification is to he filed at the Election Board where the committee's campaign reports are filed.
CRO-3100 Certification of Treasurer June 2007
r �
RECEIVED
North Carolina FEB 0 8 2010
State Board of Elections NHC Bd , " =sections
506 N Harrington Street
Raleigh,NC 27603
Kimberly Westbrook-Strach Mailing Address
Deputy Director—Campaign Reporting PO Box 27255
Raleigh,NC 27611-7255
(919) 733-7173
Fax: (919) 715-8047
Candidate Designation of Committee Funds
This form is used by candidate committees only and allows the candidate to designate in the event of their death,
how the committee's funds are to be disbursed using the eight allowable methods outlined in 163-278.1613(a).
Candidate Name: -\w\1 GaC, c—"CAGc\e,�)
Committee Name: 1✓keJc--t L\\\\ukN —k ttR-
Treasurer Name: Q, • P\A k\r1`
If Candidate is own treasurer, designate an agent to carry out designations:
Committee ID#:
Level Registered: [State] [County] If county, specify:
I, Li 11 k n tJCt`��e5 (S -' ht, hereby direct that in the event of my death or incapacity all
(Name of Candidate)
funds remaining in my Campaign Committee account(s) (after payment of permitted outstanding
debts or reasonable expenses for winding up the Committee or closing office) be paid in the
following manner as permitted by N.C. Gen. Stat. 163-278.16B(a).
Name of Entity Plan for Disbursement (eg. Amount or%)
(Select from§163-278.16B(a))
2.
3.
By signing this form, I certify that the foregoing entities are eligible beneficiaries under N.C.
Gen. Statute 163-278.16B(a). A copy of this form should be maintained with the Committee
records.
Signature of Candidate: -
Dat - U�
Note:This Designation is to be tiled with the Election Board where the committee's campaign reports are Sled.
CRO-3900 Candidate Designation of Committee Funds June 2007
North Carolina
State Board of Elections
506 N Harrington Street
Raleigh,NC 27603
Kimberly Westbrook-Strach Mailing Address
Deputy Director—Campaign Reporting PO Box 27255
Raleigh,NC 27611-7255
(919) 733-7173
Fax: (919) 715-8047
Certification of Inactive Status
This certification is used by Candidate,Party,PACs and Referendum Committees to declare their intent to be inactive,
which is not raising or spending any money on behalf of the campaign
FILED BY:
Committee Name: ��' � f`C T j-- t l 1 f� r-) c (-
Treasurer Name: o ,J t r cA ,
Treasurer Address: q p /19 C .v A E, (7v U
(include city,state,&zip) Lj L y- 4 U -3
)
Treasurer Phone: i ) U 3 .2- j D D C;
I certify that the above named candidate/political committee intends to receive no contributions,nor make
any expenditures,until the committee resumes activity.
I understand that if the above circumstances change,it will be necessary for the person responsible for
filing financial disclosure reports to file an amended Statement of Organization and the Certification to
Return to Active Status form(CRO-3300)within ten days.
L
ate Sign d Signature
Note:This Certification is to be riled at the Election Board where the committee's campaign reports are filed.
RECEIVED
AUG 2 0 2012
IL. r01 '^ "-1 ^f Elections
CRO-3200 Certification of Inactive Status June 2007