Amin Organizational Information Amendment
Statement of Organization - Candidate Committee 113 Yea No
1.C5Nae Information
t F —` c.ID Number
`O V AAL M.Ms(include City,State and Zip Code) d.Date Organized
Val,�r►,�t �iJ+� �1 `s L.,���� e.Phone Number
BLit- 111`.
2.Candidate Information U Candidate's Primary Committee
Full Name L/�, c.Candidate ID Number d.Party Affdiation
r/
Mailing Address(include City,State,and Zip Code) e.Office Sought E Jurisdiction
5 (If office sought is nonpartisan, write "Nonpartisan"in J
Party Affiliation.)
FN Information 4.Custodian of Books Information
a.Full Name
ess(include City,State,and Zip Code) b.Mailing Address(include City,State,and Zip Code)
tv A L� \w v�mac.• r r d.Email Address c.Phone Number d.Email Address
,o5
S V-
5.Assistant Treasurer Information U Add 6.Account Information (incL CRO-3500) U Add
a.Full Name ❑ Remove a.Financial Institution Full Name ❑ Remove
' 1 ",:mL NA ,a c.
Mailin ddress(include City,State,and Zip Code) b.Purpose
.Phone Number d.Email Address c.Code d.Type
1�
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 complet {ue and correct.
ah ��.M.,:3•. Z.ocY
Printed Name of Signer Sign re of Tpo6ted Treasurer Date
CRO-2100A NC State Board of Elections May 2003
kEGLIVED
MAR 13 2006
TIME RECD Br
NEW -00VER M 01 (IF fl-FOON
.�h
North Carolina
State Board of Elections
506 N Harrington Street
Raleigh,NC 27603
Kimberly Westbrook Mailing Address
Deputy Director—Campaign Reporting PO Box 27255
Raleigh,NC 27611-7255
(919) 733-7173
Fax: (919) 715-8047
Certification of Threshold
FILED BY: , 1
Committee Name:
Treasurer Name:
Treasurer Address: �/O �'j'�`' 74' Jj
(include city,state,&zip) VJ`,,tv,;, j ► �l L', Z.'tti0 i
Treasurer Phone:
Check One:
✓I certify that this committee intends to neither receive nor expend more than$3,000 during the current
election 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.
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.
0 j' 7
Date Signed
Siknature
CRO-3600 Certification of Threshold March 2003
North Carolina
State Board of Elections
506 N Harrington Street
Raleigh,NC 27603
Kimberly Westbrook Mailing Address
Deputy Director—Campaign Reporting PO Box 27255
Ueigh,NC 27611-7255
(919) 733-7173
Fax: (919) 715-8047
Certification of Treasurer
FILED BY:
Candidate Name: ,-4 W L'0 ri
Treasurer Name: i)�Clblt4. C. (S o--'J r4'-'A--s
Treasurer Address: L I n u S 4. ]*'-
(include city,state,&zip) NA1
Treasurer Phone:
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.
Date S geed Signature of Candidate
CRO-3100 Certification of Treasurer March 2003