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HomeMy WebLinkAboutO'Grady Organizational Forms Amendment Statement of Organization - Candidate Committee ❑ lies ® 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,only re-submit if applicable). 1.Committee Information Full Name c.ID Number Co M M J T` -/-0 x°e L Z CC. 1 K-t>Y/V,/ 01 x L> Mailing Address(include City,State and Zip Code) d.Date Organized a-oo !�;- j T-H" C4 I`-v 4IJL 15 201.e.Phone Number 1{0 _ 2.Candidate Information [:]Candidate's Primary Committee •.Full Name e.Candidate ID Number f.Party Affiliation 1,41A1-PA171SjA,1 V (Indicate Non-partisan if applicable) b.Mailing Address(include City,State,and Zip Code) g.Office Sought 417 XJ>Y a S-t Gf/r�tif,��TO�'/ o�Ff�O) �17J'�au.���1 J L awl/�vj T-cly c.Phone Number d.Email Address h.Next Election Year i.Jurisdiction 9V 'S�-vO b o 1. Email copy of notices 3 ���tGNJ/N j>"d�w� J 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) WILp'jVC (-VIU N<e, Z�(�e+ ��- Wi 4 N Z 1` ooAdd'- c.Phone Number d.Email Address c.Phone Number d.Email Address 510 6?4 G3} �i►+cdonaa i9�F4 ��wlail. `)[c�6 i 1FG �rniLAo.+nc, i5 � I refer to receive notices b email Yes No Email co of notices 5,Assistant Treasurer Information Add 6.Account Information (incl.CRO-3500) Full Name ❑ Remove a.Financial Institution Full Name ❑ Remove w� -S (Aj J b.Mailing Address(include City,State,and Zip Code) b.Purpose C -mj��rG� c.PhoneNumber d.Email Address c d.Type C-J�ZCL f/l. ! El Email co of notices / r 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. hzl k- Mrs Joy u 2 —'� (L c3 Printed Name of Signer Signature of Appointed Treasurer Date CR0-2100A NC State Board of Elections July 2011 Amendment Statement of Organization Addendum Page --4— of -�— ❑ Yes EI No Use this form to supply additional assistant treasurer information or additional account information This form must be accompanied by form CRO-3500 if additional accounts are being reported 1.Committee Full Name(and Fund if applicable) 2.ID Number 3.Assistant Treasurer Information Add 4.Account Information (1ncL CRO-3500) Add a.Full Name ❑ Remove a.Financial Institution Full Name ❑ Remove tw e b.Mailing Address(include City,State,and Zip Code) b.Purpose ,; L U t C- c. Phone Number d.Email Address c.Account Code d.Type 3.Assistant Treasurer Information I Lj Add 4.Account Information (inct.CRO-3500) Add a.Full Name ❑ Remove a.Financial Institution Full Name I❑ Remove b.Mailing Address(include City,State,and Zip Code) b.Purpose c.Phone Number d.Email Address c.Account Code d.Type 3.Assistant Treasurer Information L_j Add 4.Account Information (incl.CRO-3500) Add a.Full Name ❑ Remove a.Financial Institution Full Name I❑ Remove b.Mailing Address(include City,State,and Zip Code) b.Purpose c.Phone Number d.Email Address c.Account Code d.Type 3.Assistant Treasurer Information U Add 4.Account Information (incl.CRO-3500) Add .Full Name ❑ Remove a.Financial Institution Full Name ❑ Remove Mailing Address(include City,State,and Zip Code) b.Purpose Phone Number d.Email Address c.Account Code d.Type CERTIFICATION I certify that the Committee is in compliance with all provisions of Article 22A,including that no funds are commingled with funds for a federal or out-of-state PAC. I further say that this report is complete,true and correct. Printed Name of Signer Signature of Appointed Treasurer Date CRO-2110 NC State Board of Elections April 2007 North Carolina State Board of Elections 441 N Harrington Street Raleigh,NC 27603 Kim Westbrook Strach Mailing Address Executive Director PO Box 27255 JUL 15 2013 Raleigh,NC 27611-7255 (919) 733-7173 F_ 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: _, / n Candidate Name: L V 1 �R!T.l)Y Treasurer Name: j=-A 11 �K �� �D,c1�c/ - Treasurer Address: ;jx(9 j ti o4(-H g-1-)q9 pL A(�C_ (include city,state,&zip) 01 L-MIA 'fir 7011 , /(/Ok%(f C#4bt&4- AZ4 0� Treasurer Phone: 9 10 (u 7 9 �6 3 7 (1-0 9 lo -LVz Mkcv 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 163.278.9(k). to Signed Signatu f Candid Note:This Certification is to be filed at the Election Board where t e committee's campaign reports are filed. CRO-3100 Certification of Treasurer May 2013 `k North Carohna JUL 15 2013 State Board of Elections 506 N Harrington Street N HC 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 nine allowable mekods outlined in 163-278.16B(a). Candidate Name: Je6V1V ©`G 4,P y Committee Name: COMM/ 7T 'C- 7V /�� T k-�ylKr Oe GOM )Y Treasurer Name: If Candidate is own treasurer,!designate an agent to c ignations: Committee ID Level Registered: [State] [Count county, 5ygcify: 1,.Z "V�,O Cri2.a 0/ , he 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§16/3-2278.16B(a)) 1• i>'STJC /!/312GSS15 IOU,UDdt/�� `©0 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 uld be maintained with the Committee records. Signature of Candidate: Date: Li Note:This Designation is to be filed with the Election Board where the committee's campaign reports are Tiled. CRO-3900 Candidate Designation of Committee Funds December 2009