Statement of Organization - Candidate CommitteeUse this lbrm to create a ne',v or update an existing candidate committee.

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l. Commiftee InlbrmationFull Name ID Nunher

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Itlailing Address (includc City, State and Zip Code) d. Date Organizcd

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C*ndidate Information Candidate's Primarv Com mittee

L. Full Name ]. Candidate ID Number f. Party Affiliation

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Indicate Non-panican if applicable

Nlailing Address (include City, State, and Zip Code) g. Office Sought

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Phone Number d. Email Address h. Nert Election Year . Jurisdiction

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El Email copy of notices

. Treasurer lnformation 4. Custodian of Books Information, Full Name a. Full lt[ame

r. Nlailing Address (includc City, State, and Zip Code) b. Nlailing Address (include City, State, and Zip Code)

3:. Phone \umber Email Address Phone Number l. Email ,\ddress

I nrefer to receive notices bv email Yes I lNo Email conv o noticesi. Assistant Treasurer ln formation trt' Add

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5. Accorrnf lnformation rrrcl. (-RO-Jj4or ll ,l Add

r. Financial lnstitution Full ),lame ll-l RemoveFull Name

r. llailing Address (include City, State, and Zip Code) r. Purpose

Phone Numher d. Email Address r. r\ccou nt Code d. Type

I I Email coDv oI noticesERTIFICATIONI cerrill,that the Conrmittee or Fund is in conrpliance rvith all applicable provisions of Article 2.2A,228 &22D-22N1 ofChapter 163 of the NC General Statutcs and that no f'unds are commingled rvith prohibited or c,thel non-disclosed 1unds.

I furlher certify that this report is complcte. true and correct.

Srlnrture ofApporntcd I rea:rrerPrintcd Name ol'Signer Dale

NC State Board ofElections Ma1 201 1

State Board of Elections506 N Harrington Street

Raleigh, NC 27603

ICmber\ Westbrook-StrachDepury Director - Campaign Reporting

Nlailing Address

PO Box 27255Raleigh, NC 27 611-7255

(ele) 7 33-7 1t 3

Fax: (919) 715-8047

Certification of Treasurer

This Certification is used by Candidate Committees to appoint a treasurer to the committee. This form rsrequired and must accompany the Candidate's Statement of Organization

FILED BY:Candidate Name:

Treasurer Name:

Treasurer Address:

(include city, state, & zip)

Treasurer Phone: ' d ,'li \i. jll l., i,i 1

I certify that the above information is correct, and I, as candidate, appoint said treasurer to personally fulfillthe duties and responsibilities imposed upon the appointed treasurer and subject to the penalties and

sanctions in Subchapter VIIL Regr.Llation of Election Campaigns of Chapter i63 of the North CarolinaGeneral Statutes.

I understand that ifthe above Treasurer changes, it will be necessary to certify a new treasurer and amendthe existing Statement of Organization within 10 days of the vacancy. I further understand that the aboveTreasurer is required to receive training by the State Board of Elections within three months of thisappointment according to Article 1 63.21 8.9 (k).

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Note: This Certification is to be filed at the Election Board where the committee's campaign reports are filed.

Signature of Candi

cRo-3100 C e rtifi cati on of Tre as ure r June 2007

North CaroltnaState Board of Elections

506 N Harrington StleetRaleigh, NC 27603

ICmberly Westbrook-StrachDepury Director - Campaign Reporting

Ivlailing AddressPO Box 27255

Raleigh, NC 27611-1255(ele) 733-7173

Fax: (919) 11.5-8041

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 ofsupervisors, orsanitary district board.

FILED BY:Committee Name:

Treasurer Name:

Treasurer Address:

linclude city, state. & zip)

Treasurer Phone: tt, it -; i,'l t I

Cheqk One:

/ I certify that this committee intends to neither receive nor expend more than $ 1 ,000 during the cuffentelection cycie under the procedures set forth in G.S. 163-218.10A. This certification will remain in effectuntil the end of the election cycle for this committee. If this committee exceeds $ 1,000 in contributions orexpenditures during this election cycle, I understand that I must immediately notify the appropriate boardof 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 requiredto file the next scheduled report for all contributions and expenditures that have not been previouslyreported from the beginning of the current election cycle. I further agree to file all future reports required.

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Note: This Certification is to be filed at the Election Board where the committee's campaign reports are filed.

cRo-3600 Ce rr ificn r i on of Tlt re shr tl d December 2009

North CarolinaState Board of Elections

506 N 1'Iarrington Srreet

Relcigh, NC 27603

I{irnberlr, Westbrook-StrachDepug Dir'ector - Campaigr Reporting

tr'Iailing AddressPO Bor 27255

Raleigh, i\C 27 61 1. -7 255(919) 7 33-7 113

Fax: (919) 71-5-8047

This Certification is used to report confidential bank account information for all financial accounts

established by the committee and must accompany the Statement of Organization Form

FILED BY:

Committee Name:

Treasurer Name:

Treasurer Address:

(include city, state, & ziP)

Treasurer Phone:'i

I certify that the information provided below is true and accurate. I am providing all account information for

the above named Committee. These account numbers include all bank accounts utilized, credit card accounts,

money market or savings accounts, or any other financial account used for any purpose by the Committee'

The information provided on this form is considered confidentiai and is not subject to public disclosure. The

information p.ouid"d woutd only be used for the purposes of an audit or investigation or as required by a

court of competentjurisdiction. It will be n.."rrury to assign each account number a "account code" in order

to provide accountlnformation on required disclosure reports. If an account number is used as the "accotlnt

code", confidentiality ofthe account number is presumed to have been waived.

The treasurer shall maintain all moneys of the political committee in a bank account or bank accounts used

exclusively by the political committee and shall not commingle those funds with any other moneys.

Type of account Financial Institution Address Account Number AccountCode

By signing this statemenr, I authorize agenls of the State Board of Elections to inspect ail accounts

provided.

In lieu of providing account information, I certify that this committee lvillexcept for the filing fee. (Onl1' candidotes may choose this option')

Date Signed

cRo-3500

Signature of Candidate or Treasurer

Certification of Financial Account Information

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Date Signed

Ce rtificalion of Financial Account Infortltcttiott August 2A08

North CaroltnaState Board of Elections

506 N Harrington StreetRaleigh, NC 27603

I{imberly Westbrook-StrachDeputy Director - Campaign Repolting

Ivlailing AddressPOBox27255

Raleigh, NC 2761 1, -7 255

(ele) 733-7173Fax: (919) 715-8047

Candidate Designation of Committee FundsThis 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 aliowable methods outlined in 163-278.168(a).

Candidate Name: T*o-i.i.j J*hr, (TJ ) lho*l,,.s,^, ,ir.committee Name: fvil,ldnan{ -i.: Ficeii l-J iliry,*'r**Treasurer Name:

If candidate is own treasurer, designate an agent to carry out designations:

Committee ID #:

Level Registered: lStatel fCounty] If county, specify:

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.i.-th Thr.ni,';s:,, .,i,^. , 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 outstandingdebts or reasonable expenses for winding up the Committee or closing office) be paid in thefollowing manner as permitted by N.C. Gen. Stat. 163-278.16B(a).

Name of Entitlz( S e lect from S I 63 -27 8. I 68 (a))

Plan for Disbursement (eg. Amount or %)

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By signing this form, I certify that the foregoing entities are eligible beneficiaries under N.C.Gen. Statute 163-278.168(a). A copy of this form should be maintained with the Committeerecords.

Signature of Candidate:

Date:

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Note: This Designation is to be filed with the Election Board where the committee's campaign reports are filed.

cRo-3900 Candidate Designation of Cotnmittee Funds June 2007