01_Nichols Committee FormsAmendment
Statement of Organization -Candidate Committee DYes EI No
Use this fonn to create a new or update an existing: candidate committee.
This . fi orm must b e accomoame . db )v f onns CRO 3100 -an d CRO 3500
1. Committee Information
c.IDNumber a.Full Name
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d. Date Organized ~. Mailing Address (include Citrl-State and Zip CRe)
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e. prlOne Number ,r~r,?I~ 23#0'-'l'S'() I
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2. Candidate Information U Candidate's Primary Conunittee
d. Party Affiliation c. Candidate ID Number a. FuU Name
(l~~ A~·... ).a~?1~ ~.J.QUA V,... q./I
r. Jurisdiction e. Office Sought I V b. Mailing Address (include City,'state, and Zip Code)
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.~;; ,~ "1f~ ?It J.,f~(),~rst)1
(If office soughT is nonpanisan, wriTe "Nonpanisan" inl(d]
Party AffiliaTion.)
4. Custodian of Books Information
a.Full Name
3. Treasurer Information
a.FuUNaIDe
OI.fl _H-.J '~~~J.) (1,A~_ ~ 4'. ?2..~'~~)
ff ··or-u ··r
b. Mailing Address (include City, slate, and Zip Code) b. Mailing Address (include City,State, and Zip Code)
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. Phone Number d.'Email Address d. Email Address c. PhoneNumberV
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U Add
a.Full Name ID Remove
5. Assistant Treasurer Information IUAdd 6. Account Infonnation (incl. CRO-35(0)
a. Financial Institution Full Name D Remove
b. Mailing Address (include City, State, and Zip Code) b.Purpose
•Phone Number d. Email Address c. Account Code d.Type
CERTIFICA nON
I certify that the Committee or Fund is in compliance with all applicable 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.
further certify that this report is complete, true and correct.
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Printed Name of Signer Signature of Appointe«Treasurer r date ~ ..
CRO-2100A nr-l.-·t:, V I::U NC State Board of Elections December 2007
FEB 20 2012
NHC Bd of Elections
I
RECEIVED
FEB 20 2012
North Carolina
NHC Bd of Elections 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 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:
Treasurer Address:
(include city, state, & zip)
Treasurer Phone: ----E-f-IIlb<---1-'-qL...lL'i_-...LJ7LL.W.1.~~ _
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 Vlll. 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).
TDale ligned
Note: This Certification is to be filed at the Election Board where the committee's campaign reports are filed.
CRO-3100 Certification of Treasurer June 2007
RECEiVED
FEB 20 2012 North Carolina
State Board of Elections NHC 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
Certification of Threshold
This Certification is used to declare or withdraw a committee's intent to raise or spend $1,000 or less in the
current election cycle.
This Certification is only valid for political party committees and candidates for a county office,
municipal office, local school board office, soil & water conservation district board of supervisors, or
sanitary district board.
FILED BY:
Committee Name:
Treasurer Name:
Treasurer Address:
(include city, state, & zip)
Treasurer Phone: 9/b 799-7/?3 ..
c~one:
I certify that this committee intends to neither receive nor expend more than $1,000 during the current
election cycle under the procedures set forth in G.S. 163-278.1OA. This certification will remain in effect
until the end of the election cycle for this committee. If this committee exceeds $1,000 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 at or under the $1,000 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.
Note: This Certification is to be filed at the Election Board where the committee's campaign reports are filed.
CRO-3600 Certification of Threshold December 2009
Kimberly Westbrook-Strach
Deputy Director -Campaign Reporting
North Carolina
State Board of Elections
506 N Harrington Street
Raleigh, NC 27603
RECEIVED
FEB 20 2012
NHC Bd of Elections
Mailing Address
POBox 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,
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Treasurer Name: fJM.A¥'l&/~,&J
If Candidate is own treasurer, designate an agent to carry out deSignations:¥4~.,J:..:d,
Committee ill #: Q \1 A YTlf"----------------
Level Registered: .[S~ate] [County] If county, specify:~~u;.... ~
I, ~,L ~,(.J , hereby direct that in the event of my death or incapacity all
P (Name of Candid;;reJ
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 %)
(Seledfrom §163-278.16B(a»
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2. _
3. _
By signing this form, I certify that the foregoing entities are eligible beneficiaries under N.C.
Gen. Statute 163-278.l6B(a). A copy of this form should be maintained with the Committee
records.
Signature of Candidate:
Date: r I
Note: This Designation is to be filed with the Election Board where the committee's campaign reports are filed.
CRO-3900 Candidate Designation ojCommil1ee Funds June 2007