Piver 2021 Organizational Form Amended1. Committee Information
a. Name of Committee d. ID Number
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Address e. Date OrganizedlttS?rrfk Br.c uS.\r...o\o^ (\C- 2*403 I I'as-aorg
c. Committee Website (Optional)I f. Phone Numbcr
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r. Full Name e. Party Aflilietion
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City, Stat€, and Zip Code)Mailing Address
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c. Phonc Number I d. Ema'ii Address g. Next Election Year h. Jurisdiction I
ID
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r. Full Neme a. Full Name
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nOe-tv Address and
c. Phone Number d.hmail Adh"es.c. Phone Number d. Email Address
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i. Custodian of Boo,ks Information (Keeper of Records)
a. Full Name a. Financial lnstitution Full Neme l(ruU[,J
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Address and
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c. Phone Number d. Email Address b. Account Code u,votu 0I El(c. Type
E Email copy of report notices /cLck;(
I cenifu that the Committee is in compliance with all applicable provisions of Article 22A of Chapter 163 of
General Statutes and that no funds are commingled with prohibited or other non-disclosed funds. I further certifr that
I certi! that the information above is correct, and I, as the candidate, appoint said treasurer to personally fulfill the
and responsibilities imposed upon the appointed treasurer and subject to the penalties in Article 22A of Chapter
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of Candidate
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NC
complete, true and correct.this IS
DateofAppointed Treasurer
63 of the NC General Statutes.
Statement of Organization - Candidate Committee
Use this form to create a new or update an existing candidate committee.
This form must be form CRO-3500. An amended form is
Is this statement:I new E[ emendea
for each new election
ED
IOOA State
2021