Affdavit Waiver Civil Late Penalties formAFFIDAVIT TO
REQUEST A WAIVER OF
CIVIL LATE PENALTIES
PAGE 1 OF 2
P.O. Box 27255
Raleigh, NC
27611-7255
Mailing Address
(919) 814-0700 or
(866) 522-4723
Phone
(919) 715-0135
Fax
elections.sboe
@ncsbe.gov
E-mail
1
Information
About You Name
Address
City State Zip Code
E-Mail Address Telephone Number
•The North Carolina State Board of Elections issues civil late penalties for campaign finance reports
that are not filed by the deadlines set under North Carolina law. The due date for each report is
available on the State Board of Elections website at:
https://www.ncsbe.gov/Campaign-Finance/reporting-schedules.
•The State Board may waive a late penalty if it determines there is good cause for a waiver. A
candidate, treasurer, or other authorized agent of a committee may request a waiver on behalf of
the committee by completing and mailing, hand delivering or e-mailing a copy of the signed form to:
elections@ncsbe.gov, ATTN:Campaign Finance. A separate affidavit form must be completed for
each penalty you wish to have waived by the State Board.
•An affidavit is a statement given under oath that its contents are true and accurate. By signing this
affidavit form, you swear, under penalty of perjury and other penalties established by North Carolina
Law, that the information provided in this affidavit is true, correct, complete, and of your own
personal knowledge.
•This affidavit will be disclosed to the public as provided in the North Carolina Public Records Act.
(N.C.G.S. § 163A-1451(d))
2
Sworn Affidavit
being duly sworn, stated:
Name
1. I am over 18 years of age, of sound mind, and I have personal knowledge of the facts stated herein.
2. I am a resident of
County and State of Residence
3. I am the:Authorized Candidate for
Chair of
Secretary of
Treasurer of
Vice-Chair of
Name of Committee
AFFIDAVIT TO
REQUEST A WAIVER OF
CIVIL LATE PENALTIES
PAGE 2 OF 2
3
Signature &
Jurat
X
Signature of Affiant Date
State of North Carolina, County of __________________
Sworn to (or affirmed) and subscribed before me,
This _________ day of __________________, 20_______
Signature of Notary Public:
_______________________________________________
Printed Name of Notary Public:
_______________________________________________
My Commission Expires___________________________
Notary Stamp or Seal
2
Sworn Affidavit
(Continued)
4. The committee was assessed a penalty by the North Carolina State Board of Elections on
for the ☐ 2019 ☐ 2020
Date of Penalty
First Quarter Report
Second Quarter Report
Third Quarter Report
Fourth Quarter Report
Mid-Year Semiannual Report
Year-End Semiannual Report
5. On behalf of the committee, I am formally requesting a waiver of the penalty described in paragraph 4.
6. Please describe all facts and circumstances you would like the State Board to consider in reviewing
your waiver request. Attach additional pages if necessary.
7. The facts and circumstances described in this affidavit are true and accurate to the best of my
knowledge.