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Cooper Organizational Forms Amendment Statement of Organization - Candidate Committee ❑ Yes ❑ No Use this form to create a new or update an existing candidate committee. This form must be accompanied by forms CRO-3100 and CRO-3500(when amending, onl re-submit it'appi icable). 1.Committee Information a.Full Name c.iD Number ( -"V HA 193 b.Mailing Address(include City,State and Zip Code) ° d.Date Organized - ll-col 3 JUL 19 2013 -T- e.W � Phone Number — ---------- NHC Bd of Elections 9 2.Candidate Information W ❑Candidate's Primary Committee .Full Name c.Candidate ID Number C Party Affiliation ]j dd (Indicate Non-parucan it applicable) b.Mailing Address(include City,State,and Zip Code) g.Office Sought H CID . 0-y-1 i/J.i,n , Phone Number d.Email Address h.Next Election Year i.Jurisdiction lie-If 9 z(b7 k 00t? j ti L ❑Email cope of notices 3.Treasurer Information 4.Custodian of Books Information a.Full Name a.Full Name b.Mailing Address(include City,State,and Zip Code) b.Mailing Address(include City,State,and Zip Code) s tsrsfrN Z�l�_ lla t, ��1 ►va C 3 Phone Number d.Email Address c.Phone Number d.Email Address L 7 44 I'c.7 �r N ��9`�2c'c'7 I prefer to receive notices by email 0 Yes U No Email copy of notices 5.Assistant Treasurer Information Add 6.Account Information (incl.CRO-3500) Add a.Full Name ❑ Remove a.Financial Institution Full Name ❑ Remove r b.Mailing Address(include City,State,and Zip Code) b.Purpose L Ake c.Phone Number d.Email Address c.Account Code d.Type 7W-2 W - - Email copy of notices 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 and correct. t-�e r.Goe>fv-y' 4 3 Printed Name of Signer Signature 6fAppointed Tr surer Date CRO-2100A NC State Board of Elections May 2011 RFc North Carolina JUL 19 2013 State Board of Elections 441 N Harrington Street NHC Bd of Elections Raleigh,NC 27603 Kim Westbrook Strach Mailing Address Executive Director 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: Treasurer Name: A5 eOb ,63 Treasurer Address: X5(,4 zig { (include city,state,&zip) Lo�, ,M\ .t ad G Treasurer Phone: 2qq 2U -7 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 V111.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 163.278.9(k). !�l 8 da 13 L Q,zmtt. �- Date Signed ignature of Cand' ate Note:This Certification is to be filed at the Election Board where the committee's campaign reports are riled. CRO-3100 Certification of Treasurer May 2013 RECD IVED JUL 192013 North Carolina NHC Bd of Elections State Board of Elections 441 N Harrington Street Raleigh,NC 27603 Kim Westbrook Strach Mailing Address Executive Director PO Box 27255 Raleigh,NC 27611-7255 (919) 733-7173 Fax: (919) 715-8047 Certification of Threshold -A This Certification is used to declare or withdraw a committee's intent to raise or spend$1,000 or less in the current election cycle. This Certification is only valid for political party committees and candidates for a county office, municipal office,local school board office,soil &water conservation district board of supervisors,or sanitary district board. FILED BY: Committee Name: Y!�Q �l`i Ctxapt?Y Treasurer Name: VV,-e. JL•�Z m b 0.1-° Treasurer Address: 3 41 s T s fire�- (include city,state, &zip) ;� 1 h ) G o2 e,�Q 3 Treasurer Phone: Che One: I certify that this committee intends to neither receive nor expend more than$1,000 during the current election cycle under the procedures set forth in G.S. 163-278.10A. This certification will remain in effect until the end of the election cycle for this committee. If this committee exceeds$1,000 in contributions or expenditures during this election cycle, I understand that I must immediately notify the appropriate board of elections and file required campaign finance reports. THIS DECLARATION CAN ONLY BE MADE AT THE BEGINNING OF AN ELECTION CYCLE. I am withdrawing my Certification to remain at or under the$1,000 threshold. I will now be required to file the next scheduled report for all contributions and expenditures that have not been previously reported from the beginning of the current election cycle.I further agree to file all future reports required. ate Signed Signature Note:This Certification is to be tiled at the Election Board where the committee's campaign reports are riled. CRO-3600 Certification of Threshold May 2013 JUL 1 2013 North Carolina NHC Bd of Elections State Board of Elections 441 N Harrington Street Raleigh,NC 27603 Kim Westbrook Strach Mailing Address Executive Director 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 163-278.16B(a). Candidate Name: QS-''t-CO-n e— Committee Name: '�^� Treasurer Name: 0_)DC V e If Candidate is own treasurer, designate an agent to carry out designations: Committee ID#: Level Registered: [State] [County] If county, specify: I, r44xn)CA r. C-o©�_, hereby direct that in the event of my death or incapacity all (N*6e 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))e I I 1. �- /VU t rue 4- 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: Date: Note:This Designation is to be filed with the Election Board where the committee's campaign reports are filed. CRO-3900 Candidate Designation of Committee Funds May 2013