01_OShields Committee FormsRECEIVED
FEB 10 Z01Z
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
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,
how the committee's funds are to be disbursed using the eight allowable methods outlined in 163-278. 16B(a).
Candidate Name: {3~ tJSj,/ekts . __. .
Treasurer N arne:
Committee Name: (11ttW.* 7& ~led£Bvtk..t:>' Jh'2~
ehAd ~'SAJd:Jrl'S
t-L.
If Candidate is own treasurer, designate an agent to carry out designations: _
Committee ID #:
Level Registered: [State] [County] If county, specify:----"J~UV J:Sfl:tJ"'o~
I,13t>4b cl.:5 b .'~ lei $ , hereby direct that in the event of my death or incapacity all
(Name of Candidate)
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.l6B(a).
Name of Entity Plan for Disbursement (eg. Amount or %)
(Select from §163-278.16B(a»
I.BN'E VAUIY 1S!tf7lsr~ll~ \OD%
2. [WIt .. M. N.c...) _
3. _
By signing this form, I certify that the foregoing entities are eligible beneficiaries under N.C.
Gen. Statute 163-278.16B(a). A copy of this form Si[:;0Uld b maintained with the Committee
records. "L:J
Signature of Candidate: ~~ d
Date: OL -lb -/2...
I
Note: This Designation is to be flied with the Election Board where the committee's campaign reports are filed.
CRO-3900 Candidate Designation of Committee Funds June 2007
Amendment ~
Statement of Organization -Candidate Committee Dyes l8'No
Use this fmm to create a new or update an existing candidate committee.
d. Type -----------------1 AttOUDt Code --1----d. Email Address PlloDe Number
eo Candidate ID N um ber f. Party AffIliation
~2LlliC2.A-10
FuUName
• Candidate Information Candidate's Primary Committee
• MailiDg Address (iadllde City, State, aDd Zip Code)
--------;1-
1. Committee Information
This form must be aeco ied b forms CRO-3100 and CRO-3500 when arnendin
I------II-V-fo':-------------L.:=------f-
Email co of notices
ERTIFICA TION
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.
CHI\-!> 0st-t1E"l,bs ~~$ -0&4"2
Printed Name ofSigoer Signature~urer TL r
CRO-2100A NC State Board of Elections July 201 J
RECEIVED
FEB 10 2012
NHC Bd of Elections
f,
North Carolina
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: q/()-5~~-2.'1_3~B _
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 VllJ. 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).
Date Signed
Note: lbis Certification is to be moo at the Election Board where the committee's campaign reports are moo.
CRO-3/00 Certification of Treasurer June 2007
R E ,C r:::'"r::0'~ ~"_ .,' t._. ! W t~
FEB 10 2012
NHC Bd of Elections