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Koeppel Organizational Information f 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: n A Treasurer Name: Treasurer Address: %' C� /��D �f'3 (include city,state,&zip) Treasurer Phone: 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. Tate Sighed Signature te:This CerRCArAVE 1&tiled at the lection Board where the committee's campaign reports are filed. ,,``��-- FEB 7 2008 RECD O C § --�" R CTY 8D.OF ELECT /(cation of Inactive Status June 2007 Amendment Statement of Organization - Candidate Committee ❑ Yes ivo 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 .� "Wnittee.IllforrmHon u a.Full Name c.ID Number V 7 b.Mailing Address(include City,State and Zip Code) d.Date Organized 0/0 -7 e.Phone Number be 7 l?z7 2.Candidate Information LJ Candidate's Primary Committee a.Full Name c.Candidate tD Number d.Party Affiliation b.Mailing Address(include City,State,and Zip Code) e.Office Sought f.Jurisdiction A,/1Z (If office sought is nonpartisan, write "Nonpartisan"in[d] Party Affiliation.) Treasurer I�on, 4.'Custodlan;of Boo s tnforl atlton Full Name a.Full Name — — -- - _ b.Mailing Address(include City,State,and Zip Code) b.Mailing Address(include City,State,and Zip Code) c.Phone Number d.Email Address c.Phone Number d.Email Address .Assistant Treasurer'Infarluation Add +6.Aecount Information fi&L CRO-3500) Acid '. a.Full Name Ej Remove a.Financial Institution Full Name ❑ Remove S 7 'Cr S-7— b.Mailing Ad ess(include i ) b.Purpose 2007 c.Phone Numb r d.Email Address c.Account Code d.Type RECD'O" 11MEt MANNER CTY. BD. bF ELECTIONS CERTIFICA 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 Trea rer Dad CRO-2100A NC State Board of Elections April 2007 RECEIVED JUL 3 U 2007 North Carolina State Board of Elections TIME_ __— RECD BY_ 506 N Harrington Street NEW NdNOWR CTY BD OF ELECTIONS 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 Threshold This Certification is used by Candidate and Party Committees only,to declare or withdraw the committee's intent to raise or spend under$3,000 in the current election cycle FILED BY: Committee Name: Treasurer Name: Treasurer Address: (include city,state, &zip) 441- Z5' OZE 7 7 Crl /2 6 D Treasurer Phone: C eck One: I certify that this committee intends to neither receive nor expend more than$3,000 during the current e ection 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$3,000 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 under the $3000 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 Sign}d ignature Note:This Certification is to be filed at the Election Board where the committee's campaign reports are filed. CRO-3600 Certification of Threshold June 2007 MNorth Carolina ----'— State Board of Elections 506 N Harrington Street ECI�GN 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: Treasurer Name: Q,/' «/ Treasurer Address: (include city, state, &zip) Treasurer Phone: /f fF"rf� 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). )Z � Date Sign 6d Signature of Can ' ate Note:This Certification is to be filed at the Election Board where the committee's campaign reports are filed. iLCRO-3100 Certification of Treasurer June 2007 RECEIVED J U L :30,:20]07 North Carolina TIME REC'DBY State Board of Elections NEW HA"ER CTY. BD,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 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: Committee Name: Treasurer Name: If Candidate is own treasurer, designate an agent to carry out designations: Committee ID#: Z- S� 7 ? Level Registered: [State] [County] If county, specify: C OGv' 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)) 1. S T T14 Ile Y 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: .SD Note:This Designation is to be riled with the Election Board where the committee's campaign reports are filed. CRO-3900 Candidate Designation of Committee Funds June 2007