Berger 2010 Fourth Quarter Amendment Disclosure Report Cover endment
Cr� Yes ❑ No
Use this form for general report and committee information,must be signed and submitted along with other detailed forms.
Do not use this form to u'date information.
1.Committee Information
a.Full Name c.ID Number
b.Mailing Address(include City,State and Zip Code) d.Date Filed
1-) fu—A-0-^---
f r et /y, l/)C. - S-7"? e.Phone Number
,S-
2. Year 3.Period Start Date mm/dd/yy) 4.Period End Date(mm/dd/yy) 5.Treasurer Full Name
r / 2 /e d, O (e--7 3,/ t- I 0 g i`2v /--y___
6.Type of Committee(Check One) 9.Type of Report (check only one type of report from one category)
❑ Candidate Campaign ❑ Party Municipal State/County Referendum
❑ PAC ❑ Referendum ❑ Organizational ❑ Organizational ❑ Organizational
❑ Independent Expenditure ❑ Joint Fundraiser ❑ Thirty-five day Quarterly ❑ Pre-referendum
❑ Legal Expense Fund ❑ Pre-primary ❑ First in Final
❑ Pre-election ❑ Second ❑ Supplemental Final
7.T (if applicable,chi ❑ Pre-runoff ❑ Third ❑ Annual
❑ Booster Fund Semi-annual Es Fourth ❑ Special
❑ Building Fund ❑ Mid Year Semi-annual
❑ Year End ❑ Mid Year 10.Special Report Name
❑ Other: ❑ Final ❑ Year End
8.Number of Fundraisers this Report ❑ Special ❑ Final
-_ ❑ Special
11.Account Information 11.Account Information
a.Financial Institution Full Name a.Financial Institution Full Name
�J 't GLs v Lv-b.Purpose c.Account Code b.Purpose c.Account Code
47 11-' _ RECEIVED
? /f� i( - d.Period Begin Balance
JUN 2 9 2011 d.Period Begin Balance
CERTIFICATION I�C Bd of Elections
I certify that the Committee or Fund is in compliance with all appl ca a 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 and that I have been trained by the NC State Board of Elections.
72,/; a. B 1(4/ t cal
Printed Name of Si er Signature of Appointed Treasurer Date
FOR OFFICE USE ONLY
Date Received: Employee: Delivery Method
❑ Normal Mail
Date Postmarked: Employee: ❑ Registered Mail
❑ Hand Delivered
Date Scanned: Employee: ❑ Electronically Filed
❑ Signer has not received
Date Data Entered: Employee:
mandatory training
Please Note:This form cannot be used to amend committee information such as the committee address,treasurer,
assistant treasurer,custodian of books information,or account information.
You must amend the Statement of Organization(CRO-2100A-E)to make committee changes.
CRO-1000 NC State Board of Elections August 2008
Detailed Summary dment
Yes No
Use this form to summarize all disclosure reporting forms and to total monetary information
1.Committee Full Name(and Fund if applicable) 2.Type of Report 3.ID Number
of Election Cycle: January 1, Total this Total this
Reporting Period Election Cycle
4) Cash on Hand at Start $ 70l Ti $
RECEIPTS' .
5) Aggregated Contributions from Individuals (cRO-1205) $ $
6)Contributions from Individuals (CRO.1210) $ £ $ 31 0
7) Contributions from Political Party Committees (CR0-1220) $ 5-01) $
8) Contributions from Other Political Committees (CRO-1230) $ S--Da` $ II 0 —
9) Loan Proceeds (CRO-1410) $ $
10) Refunds/Reimbursements to the Committee (CRO-1240) $ $
� 4
11) Other Receipt Sources ., �� ''
11a) Interest on Bank Accounts (CRO-1250) $ $
11b) Contributions from Not-For-Profit Organizations (CRO-1250) $ 1 $
11c) Outside Sources of Income (CRO-1250) $ $
11d) Legal Expense Fund-Other Sources (CRO-1270) $ $
11e) Exempt Purchase Price Sales (CRO-1265) $ $
12) TOTAL RECEIPTS(Add lines 5,6,7,8,9,10,11a,1 l b,I l c,I I d and Ile) $ $
EXPENDITURES
13) Disbursements
13a) Operating Expenditures (CRO-1310) $ $ f t yo/, /.3
13b) Contributions to Candidates/Political Committees (CRO-1310) $ $
13c) Coordinated Party Expenditures (CRO-1310) $ $
14) Aggregated Non-Media Expenditures (CRO-1315 $ $
15) Loan Repayments (CRO-1420) $ "Z_;od , $ G ate:
16) Refunds/Reimbursements from the Committee (CRO-1320) $ $
17) In-Kind Contributions __.. (CRO-1510) $ $ `f fr
18) TOTAL EXPENDITURES(Add lines 13a,13b,13c,14,15, 16 and 17) $ c L 9 s, z 3 $ 31T 7?,.i't
19) Cash on Hand at End(Add lines 4 and 12 together,then subtract line 18;) $ Z, VC $ S"rt.
ADDITIONAL INFORMATION
20) Non-Monetary Gifts Given to Other Committees (CRO-1330) $
21) Outstanding Loans(incl.ones from other campaigns) (CRO-1430) $ S�h�
22) Debts and Obligations owed by the Committee (CRO-1610) $
23) Debts and Obligations owed to the Committee (CRO-1620) $
24) Account Transfers Within the Committee (CRO-1720) $
25) Administrative Support (CRO 1710) $ nE^E) ED
26) Forgiven Loans (CRO-1440) $
27) 48-Hour Notice Reports Sum (CRO-2220) $ JUN 29
28) Contributions to be Refunded (CRO-1215) $ Alt-,Hr $
CRO-1100 NC State Board of Elections �d Q1)BCfjOns August 2008
Amendment
Contributions from Other Political Committees pg _L of �9 Yes ❑ No
Use this form to report contributions from other candidate,referendum or PAC committees
omnu -,' ull aine I an a� 7._.
w..
owit A-. l• 'l1Illte'�
49( 7--
.
3.Contributor Information Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Type of Committee d.Comments
(include city,state,&zip) ❑ Candidate 121 PAC
❑ Referendum
c.Level Registered(Specify)
h1'-/ ‘ 5 7 ?. /., ❑ Federal ❑ County:
/ 1 ri/C- 9 f/ ❑ State ❑ Municipality: e.Election Sum to Date
V" CC S
5-2(2
f.Account Code g.Form of Payment h.In-Kind Description i.Date(mm/dd/yyyy) j.Amount
( Z■ , - 2-/p $ $-be , csb
$
3.Contributor Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Type of Committee d.Comments
(include city,state,&zip) ❑ Candidate ❑ PAC
❑ Referendum
c.Level Registered(Specify)
❑ Federal ❑ County:
❑ State 0 Municipality: e.Election Sum to Date
$
f.Account Code g.Form of Payment h.In-Kind Description i.Date(mm/dd/yyyy) ,,j.Amount
$
$
3.Contributor Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Type of Committee d.Comments
(indude city,state,&zip) ❑ Candidate ❑ PAC
❑ Referendum
c.Level Registered(Specify)
❑ Federal ❑ County:
❑ State ❑ Municipality: e.Election Sum to Date
1.Account Code g.Form of Payment h.In-Kind Description i.Date(mm/dd/yyyy) j.Amount
$
S
A ECEIVED
4.Total only this Page JUN 2 9 2 n t 1 $ ,SaO„ uo
5.Total of ALL CRO-1230 Pages $
(This line must be on line 8 of Detailed a'ygde6tQ=(O9 irinc 67T-0 cJ73
CRO-1230 NC State Board of Elections April 2007
1 Ame went
Loan Repayments Pg of J� Yes ❑ No
Use this form to report payments on an existing loan.
1.Committee Full Name(and Fund if a •livable) 2.ID Number
(a -
3.Lender Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Comments
(include city,state,&zip) 3 -r� v t,o
10 CA
� c.Original Loan Date
I 45
—emu d.Original Loan Amount
$
e.Remaining Loan Balance f.Account Code g.Form of Payment h.Date(mm/dd/yyyy) i.Repayment Amount
$ 12 $ _Z or a a --
$ $
3.Lender Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Comments
(include city,state,&zip)
c.Original Loan Date
d.Original Loan Amount
$
e.Remaining Loan Balance f.Account Code g.Form of Payment h.Date(mm/dd/yyyy) i.Repayment Amount
$ $
$ $
3.Lender Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Comments
(include city,state,&zip)
c.Original Loan Date
d.Original Loan Amount
$
e.Remaining Loan Balance f.Account Code g.Form of Payment h.Date(mm/dd/yyyy) i.Repayment Amount
$ $
$ $
4. Total only this Page $ Z emu,
5.Total of ALL CRO-1420 Pages $ 2
(This line must be on line 15 of Detailed Summary Page CRO-1100) 0 L7 8
CRO-1420 NC State Board of Elections December 2007
RECEIVED
2 9 2011
NHC BJUN d of Elections
Amendment
Outstanding Loans Pg 1 of / ,-Yes ❑ No j
Use this form to report any outstanding loans received during a previous reporting period and until the loan is paid in full.
1.Committee Full Name(anti iiid f appli'ca7hle ''
736;4— X72.--1 7(--- 6,,.17 Ce
3.Lender Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Job Title/Profession d.Comments
(include city,state,&zip) //✓G c V / A-9'
Bn1c-. g c ', .^ter„/L iS
e.Start Date(mm/dd/yyyy)
8-.2-—) 4»,r,.-terra (A), c.Employer's Name/Specific Field
CO l/
t C/ / L / 1_dCP
`/ /t X Z 7 / „- G v f.End Date(mm/dd/yyyy)
Ci
ctio " y3i -dui- /p
g.Rate h.Security Pledged i.Original Loan Amount j.Remaining Loan Balance
b lin
% $ S Oo • o( $ .
k.Full Name of Lending Institution L Loan Number
3.Lender Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Job Title/Profession d.Comments
(include city,state,&zip) ,tom w f
g ! P .. r�,e Iq Q✓ e.Start Date(mm/dd/yyyy)
J / / c.Employer's Name/Specific Field
/( /�.)L 1L 1 1 / f.End Date(mm/dd/yyyy)
1 cf,0 . y;/- ,3/(_
g.Rate h.Security Pledged i.Original Loan Amount j.Remaining Loan Balance
% $ 23-)0 $ ,OO, 6v
k.Full Name of Lending Institution I.Loan Number
3.Lender Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone b.Job Title/Profession d.Comments
(include city,state,&zip)
e.Start Date(mm/dd/yyyy)
c.Employer's Name/Specific Field
f.End Date(mm/dd/yyyy)
g.Rate h.Security Pledged i.Original Loan Amount j.Remaining Loan Balance
d % $ --v. $
k.Full Name of Lending Institution 1.Loan Number
4. Total only this Page i $ o 0 Da
5. Total of ALL CRO-1430 Pages ru— VED $ _ ,`
(This line must be on line 21 of Detailed Summary Page•CilB�Ai9 I y ED ,� 1'v
CRO-1430 ..N to Bard o2011 f Elections December 2007
4 9
NHC Bd of Elections
Loan Proceeds Statement
The individual making a loan to the committee must provide the following information.
Failure to provide all of the information requested could be a violation of campaign
reporting disclosure laws.
• Name of committee to receive loan:
g ems— /-1, 6-4
• Person lending money to committee (Lender): d
j( (c Be use iT >
• Date of loan to committee: Ca Z ( /PD
• Name of lending institution and account number (source):
'v CV<
• Amount of loan: �5
• Names of all parties responsible for payment of loan (guarantors):
• Period of loan: •4J /h.,t_
• Rate of interest of loan: :E0 ✓�-
• Security pledged for loan: o rt
, acknowledge that all of the information
(Person lending money to comet ee)
provided is complete, true, and accurate. I further understand I may not forgive a loan
that has an outstanding balance to any source.
Signature of Lender
Signature of Treasurer of Committee
This form must be submitted with the disclosure report for which the loan is initially
disclosed.
CRO-6100 Loan Prof Ea Ote-Ines t July 2007
I
NHC Bd of Elections