2012 4th Quarter Report Amendment
Disclosure Report Cover 0 Yes El 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 update information.
1.Committee Information
a.Full Name c.ID Number
CD7,2'iJ i.fu,.is- -�./ i2� 1424r aa-- .. �J Q H H Y T �E
b.Mailing Address(include City,State and ip Code) d.Date Filed
0/ g b/707 2-0a
e.Phone Number
2,'c-din1 , jc J-"474a9- SSoi gto - 799- 7/33
2.Report Year 3.Period Start Date(mm(dd/yy) 4.Period End Date(mm/dd/yy) 5.Treasurer Full Name
.Z0/2-10,.3 I°/AI /zo/L I,e/31/43 Jeanne-4 S. kl,rhAI-5
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 ❑ Final
❑ Pre-election ❑ Second ❑ Supplemental Final
7.Type of Fund (if applicable,check one) ❑ Pre-runoff ❑ Third ❑ Annual
❑ Booster Fund Semi-annual al 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
e — ; a
b.Purpose c.Account Code b.Purpose c.Account Code
`��iaGrt-d-c4.1 d.Period Begin Balance d.Period Begin Balance
$ 7S'7. 95 $
CERTIFICATION
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. I further certify that this
report is complete,true and correct and that I have been trained by the NC State Board of Elections.
j8ahln.e-R-e .5. 1\1;<116 1s ;/.a4-t.... / �� p/a7/.2.0(_?
Printed Name of Signer Signature of App inted Treasurer DXte
FOR OFFICE USE ONLY
Date Received: 11f 7/30/ 3 Employee: 46:, ---- Delivery Method
❑ Normal Mail
Date Postmarked: Employee: ❑ Registered Mail
Hand Delivered
Date Scanned: Employee: Electronically Filed
El Sier has not
Date Data Entered: Employee: mnda ory 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
Amendment
Detailed Summary ❑ 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
_moo i4,.a .4,-� 0H A YT
Total this Total this
Start s
StaCt of Election Cycle: January 1, !L
Reporting Period Election Cycle
4) Cash on Hand at Start $ 7 S7 615 $ '257---
RECEIPTS
5) Aggregated Contributions from Individuals (CRO-1205) $ $
6) Contributions from Individuals (CRO-1210) $ $ (() 9
7) Contributions from Political Party Committees (CRO-1220) $ $ 0 d, c 1/7/�i
8) Contributions from Other Political Committees (CRO-1230) $ $
9) Loan Proceeds (CRO-1410) $ $
10) Refunds/Reimbursements to the Committee (CRO-1240) $ $
il) Other Receipt Sources
11a) Interest on Bank Accounts (CRO-1250) $ $
11b) Contributions from Not-For-Profit Organizations (CRO-1250) $ $
lic) Outside Sources of Income (CRO-1250) $ $
lad) Legal Expense Fund-Other Sources (CRO-1270) $ $
lle) Exempt Purchase Price Sales (CRO-1265) $ $
12) TOTAL RECEIPTS(Add lines 5,6,7,8,9,10,11a,llb,llc,lld and Ile) $ $
EXPENDITURES
13) Disbursements
13a) Operating Expenditures (CRO-1310) $ $ j /() . U
13b) Contributions to Candidates/Political Committees (CRO-1310) $ $
13c) Coordinated Party Expenditures (CRO-1310) $ $
14) Aggregated Non-Media Expenditures (CRO-1315) $ $ O
15) Loan Repayments (CRO-1420) $ $
16) Refunds/Reimbursements from the Committee (CRO-1320) $ , ` $ '�- �L I?
17) In-Kind Contributions (CRO-1510) $ 1�1 1
47
18) TOTAL EXPENDITURES(Add lines 13a,13b,13c,14,15, 16 and 17) $ -4 $ Z$ "� yo
19) Cash on Hand at End(Add lines 4 and 12 together,then subtract line 18; $ . (4,. $ ( S e ((c-
ADDITIONAL INFORMATION
20) Non-Monetary Gifts Given to Other Committees (CRO-1330) $
21) Outstanding Loans(incl.ones from other campaigns) (CR0-1430) $
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) $ $
26) Forgiven Loans (CRO-1440) $ $
27) 48-Hour Notice Reports Sum (CRO-2220) $ $
28) Contributions to be Refunded (CR0-1215) $ $
CRO-1100 NC State Board of Elections August 2008
Amendment
Refunds/Reimbursements From the Committee Pg / of / ❑ Yes ❑No
Use this form to report refunds/reimbursements,including contributions returned to the contributor.
1.Committee Full Name(and Fund if applicable) 2.ID Number
3.Payee Information ❑ Add ❑ Remove
a.Full Name,Mailing Address Si.Phone d.Type of Committee h.Original Receipt Date
(include city,state,&zip) ❑ Candidate ❑ PAC
,‘20 Referendum El Party U2/i 7/20/2
�//�J //,��� e.Level Registered i.Original Receipt Amount
2.,S-d d ('a ,te,n ee• ❑ Federal ❑ County: /�a
/yf Y ' �e Zp '4 '9 ❑ State ❑ Municipality: $ 7 %. .0D
��OO f.Purpose Code '.Election Sum to Date
(9/e'9799- 7/33 $ C O
b.Job Title/Profession c.Employer's Name/Specific Field g.Comments k.Account Code
6-.�.,t_r r,f.�� pIke, 10e... Av,..,,C 33g
f. Payment m.Required Remarks n.Date(mm/dd/yyyy) o.Amount
Isn-4.+,c. ,
�QQ�Im /.s��i,��u s�l�,. 4��?//zv i 2 $ f 4. 6 n
3.Payee I#Sformatio st ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone d.Type of Committee h.Original tpt Date
(include city,state,&zip)
El ❑ PAC 0"9/9 /20/2
C . _ /1n �!-.4 :J_, .06,. Q Referendum D_Party 7
`��` / G_ ' /��®®���� • Level Registered i.Original Receipt Amount
�/y� gedi- " -.. .i ❑ County:
D. 'g9, !G3J State • Municipality: $ o •O X
f.Purpose Code j.Election Sum to Date
1 //C Z . ,4
�, . 2.00•on
•b.Job Tide/Profession -, Fmployer's Name/Specific Field g.Comments k.Account
I.Form of Pay m.Required Remarks • n.Date( dd/jyyyy) o.Amount
dG„ Di a� �o2, $ 65y 95
.Pnformation ❑ Add ❑ Remove /
a.Full Name,Mailing Address&Phone d.Type of Committee h.Original Receipt Date
(include city,state,&zip) ❑ Candidate ❑ PAC
❑ Referendum ❑ Party
e.Level Registered i.Original Receipt Amount
❑ Federal ❑ County: $
❑ State ❑ Municipality:
f.Purpose Code j.Election Sum to Date
$
b.Job Title/Profession c.Employer's Name/Specific Field g.Comments k.Account Code
I.Form of Payment m.Required Remarks n.Date(mm/dd/yyyy) o.Amount
$
4.Total only this Page $ 1.5-7-. 5- --=; 5 e . a o
5.Total of ALL CRO-1320 Pages $ 00
(This line must be on line 16 of Detailed Summary Page CRO-1100) � _�' 5?
6.Purpose Codes(List detailed disbursement code in(f)above) t
L-Returned to Contributor M-Overpayment for Service N- Exceeded Contribution Limit / .7
P* -Reimbursement of In-Kind 0*Other Ij
*Codes require detailed explanation in required remarks field(m)
CRO-1320 NC State Board of Elections December 2007