2012 Final Report Amendment
Disclosure Report Cover ❑ 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 update information
1.Committee Information
a.Full Name
c.ID Number
Committee to Re-Elect Jeanette Nichols QUAY-FS
b.Mailing Address(include City,State and Zip Code) d.Date Filed
2500 Carrington Court
Wilmington,NC 28409-8501 1/7/2013
e.Phone Number
910-799-7133
4.Period End Date
2.Report Year 3.Period Start Date(mm/dd/yy) 5.Treasurer Full Name
(mm/dd/y'y)
2013 1/1/2013 1/4/2013 Jeanette S.Nichols
6.Type of Committee(Check One) 9.Type of Report (check only one type of report from one category)
❑ Candidate Campaign ❑ Party Municipal State/Count■ Referendum
❑ PAC ❑ Referendum ❑ Organizational ❑ Organizational ❑ Organizational
Independent ❑ Joint Fundraiser ❑ Thirty-five day Quarterly ❑ Pre-referendum
❑ Expenditure
❑ Legal Expense Fund
7.Type of Fund Of applicable,check one) ❑ Pre-primacy ❑ First ❑ Final
❑ "Booster Fund" ❑ Pre-election ❑ Second ❑ Supplemental Final
❑ Building Fund ❑ Pre-runoff ❑ Third ❑ Annual
Semi-annual ❑ Fourth ❑ Special
❑ Mid Year Semi-annual
❑ Other: ❑ Year End ❑ Mid Year 10.Special Report Ne
❑ Final ❑ Year End
8.Number o° 9draisers this Report ❑ special ® Final
❑ Special
11.Account Information 11.Aount Information
a.Financial Institution Full Name a.Financial Institution Full Name
Wells Fargo Bank
b.Purpose c.Account Code b.Purpose c.Account Code
All Campaign 338
Expenses
d.Period Begin Balance d.Period Begin Balance
$ 658.95 $
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 _tate Board of Elections.
Jeannette S.Nichols ,,��„ at 1/07/2013
Printed Name of Signer Signature of Appointe.( reasurer Date
FOR OFFICE USE ONLY
•L / 7 Delivery Method
Date Received: t= r/ 3' f Employee:
❑ Normal Mail
Date Postmarked: Employee: ❑ Registered Mail
® Hand Delivered
Date Scanned: Employee: ❑ Electronically Filed
❑ Signer has not received
mandatory training
Date Data Entered: Employee:
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 Aueust 2008
Amendment
Detailed Summary Yes z No
Use this form to summarize all disclosure reporting forms and to total monetary information.
J.Col 1 Name(and Fund If applicable) 2 Type of Report 3„,4b Number
Committee to Re-Elect Jeannette S.Nichols 2013 Final Report QHAYT4
Start of Election Cycle: January 1, 2013 Total this Total this
Reporting Period Election Cycle
4) Cash on Hand at Start $ 658.95 658.95
5) Aggregated Contributions from Individuals (CRO-1205) $
6) Contributions from Individuals (CRO-1210) $
7) Contributions from Political Party Committees (CRO-1220) $
8) Contributions from Other Political Committees (CRO-1230) $
9) Loan Proceeds (CRO-1410) $
10) Refunds/Reimbursements To the Committee (CRO-1240) $
11) Other Receipt Sources
11a) Interest on Bank Accounts (CRO-1250) $
lib) Contributions from Not-for-Profit Organizations (CRO-1250) $
11c) Outside Sources of Income (CRO-1250) $
11d) Legal Expense Fund—Other Sources (CRO-1270) $
11 e) Exempt Purchase Price Sales (CRO-1265) $
12) TOTAL RECEIPTS(Add lines 5,6, 7,8,9, 10, Ila I If 11, 11(1 ) $
13) Disbursements
13a) Operating Expenditures (CRO-1310) $
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) $
16) Refunds/Reimbursements From the Committee (CRO-1320) $ 658.95 658.95
17) In-Kind Contributions (CRO-1510) $
18) TOTAL EXPENDITURES(Add lines I3a,13b, I3c 14, 15, 16 and 17)
19) Cash on Hand at End(Add lines 4 and 12 together,then subtract line 18) $ 0 0
20) Non-Monetary Gifts Given to Other Committees (CRO-1330) $
21) Outstanding Loans(incl.ones from other campaigns) (CRO-1430) $
22) Debts and Obligations owed By the Committee (cRo-lob ) $
23) Debts and Obligations owed To the Committee (CR0-1620) $
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-2200) $
28) Contributions to be Refunded (('RO-1215) $
CRO-1100 NC State Board of Elections August 2008
Amendment
Refunds/Reimbursements From the Committee Pg 1 of I ❑ Yes ® No
Use this form to report refunds reimbursements, including contribution,returned to the contributor.
1.Committee Full Name(and Fund if applicable) 2.ID Number
Committee to Re-Elect Jeannette S Nicols QHAYT4
3.Payee Information ❑ Add ❑ Remove
a.Full Name,Mailing Address&Phone d.Type of Committee h.Original Receipt Date
(include city,state,&zip) ❑ Candidate ❑ PAC 9/7/2012
Lower Cape Fear Republican Women's Club ❑ Referendum ® Party
Po Box 7635 e.Level Registered(Specify) i.Original Receipt Amount
Wilmington.NC 28406 ❑ Federal ❑ County:
® State ❑ Municipality: $ 2200.00
f.Purpose Code j.Election Sum to Date
_L
$ 0
b.Job Title/Profession c.Employer's Name/Specific Field g.Comments k.Account Code
N/A NA Returned to contributor 338
a portion of originial
1.Form of Payment m.Required Remarks n.Date(mm/dd/yyyy) o.Amount
Money Order 1'42013 S 658.95
3.Payee Information ❑ Add. ❑ Remove
a.Full Name,Mailing Address&Phone d.Type of Committee Ii.Original Receipt Date
(include city,state,&zip) ❑ Candidate ❑ PAC
❑ Referendum ❑ Party
e.Level Registered(Specify) 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
1.Form of Payment m.Required Remarks n.Date(mm/dd/yyyy) o.Amount
3.Payee Information ❑ 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(Specify) 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 $ 658.95
5.Total of ALL CRO-1320 Pages (This line must be on line 16 of Detailed Summary Page CRO-1100) $ 658.95
L-Returned to Contributor SJ-ON eipayment for Service N- Exceeded Contribution Limit
P*-Reimbursement of In-Kind 0*Other
*Codes require detailed explanation in required remarks field(m)
CRO-1320 NC State Board of Elections December 2007