Usethis form for general report and committee information, must be signed and submitted along with other detailed forms.

Transcription

1 Disclosure Report Cover Amendment Yes QJ-No Usethis form for general report and committee information, must be signed and submitted along with other detailed forms. Do not use this form to UDdate information. \r G'O'r.iqnt-cf. rn_"3;n.optioq -V-Vl - ta/.fullname..'....,-;-;. -.-.:..._._.-:. tutetcjujgs rot;., L^c^u-oi-^ CI* K\"\ iss Sc-Oli bjftlailing Address(includeCity/Statrand Zip Af.L.,q», im CiT&4i' nssrf.? -~ C-^c><jL*r RoaJ CLEVELAND CO. BD. ELEC H ) A>q s i^ok^aj -\~ c< l /C 71. C. ^%>jfo^.eai^ff^ib1iista itfmpl BY 1CJL&2 d: Date Filed ION e. Phone Number^ 7«</-7.l9-S7S7 Jo/Z 2g - ^yj2_ ^ -3D-3s)2- An)cL^ ssc^x-r-b'- r» ul.*j C coi^ommi'reefcsdecb':qn ~0-': '';.' Candidate Campaign Q p2ity PAC Referendum n Independent Expenditure Q Joint Fundraiser L_J Legal Expense Fund IjI&SlJibTiSia^ I i Booster Fund [n Building Fund Other: 8^ii^ Kgj/^uiitIr^sers:thj^Rep^rtgg^ l&o&rep'pjftm-fc/'^ Municipal f.-. I i Organizational I I Thirty-five day i~l Pre-primary n Pre-election n Pre-runoff Semi-annual Mid Year Year End F.nal Special State/County-;"- I I Organizational f~i Quarterly First \B^ Second Third Semi-annual Mid Year Year End Final Special Hi^^tmtljif^manorrc-vj ~ Xk, --Accoun i Inibimatit) 11 a Financial lasmuuon'fuli Name isu.i; 'd; Purpose_-. Depos i rs /M^sr' ^>c*-aj X f avfinaricial Institution Full Name Referendum-'. I I Organizational I Pre-referendum Final I I Supplemental Final I I Annual Special 'M^V lt?;sped^ifieportyanie.v: c. Account Code - -.: b.;purpose Account Code - ^ >/ rl:peripd:6egjn'balance s Lffl drperiod Begiri Balance.'.^IMffiQATION..-, I certify that the Committee orfund isin compliance with all applicable provisions ofarticle 22A, 22B &22D-22M ofchapter 163 ofthe NC General Statutes and that no funds are commingled with prohibited orother 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. Printed Name ofsigner I / Signature of Appointed Treasurer ;^;:D2te-Po^ SSvDateScanhed: Si'tJrrin Date.-DataEntered:-...I -- -"" -?.-. '- -.-Employee:' j_ Delivery Meipoc,---..' vnrormai Mai! l0fhlnd_'delivered-- O.ElectfonicallylEiled.:.-,, ;-Signer has not-received":.': -r.^manda.torv 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. Youmust amend the Statement of Organization (CRO-2100A-E) to make committee changes. CRO-1000 KC State Board of Elections August 2008

2 Detailed Summary Use this form to summarize all disclosure renortins forms and to total monetarv information ^^^^Ug^^^j^^^l^ig^Fgnd^^jgBJ^^I^^^^ g^/type/of Rep6rt;^>.^^ Amendment Yes [R'No 9ru.r<^);^x t>* (acsa/tf fg*, ;ss;»*.'' z?fj3 -J/svJ&& JLCJLlit \7 Start of Election Cycle: January 1, 4) Cash on Hand at Start s Total this Reporting Period /9*7JS -:^ Total this Election Cycle 5) Aggregated Contributions from Individuals (CRO-1205) 6) Contributions from Individuals 7) Contributions from Political Party Committees 8) Contributions from Other Political Committees 9) Loan Proceeds 10) RefundsTReimbursements to the Committee (CRO-1210) (CRO-1220) (CRO-1230) (CRO-1410) (CRO-1240) $ 6?SO oo $ l,g/q-oo I s,f,.q0 o 11) Other Receipt Sources 11a) Interest on Bank Accounts (CRO-1250) s ** v s o lib) Contributions from Not-For-Profit Organizations (CRO-1250) S -»>> s o lie) Outside Sources of Income (CRO-1250) $ > - s ~ t>.. lid) Legal Expense Fund - Other Sources (CRO-1270) $ - i» $ & lie) Exempt Purchase Price Sales (CRO-1265) $ "" o - s & 12) TOTAL RECEIPTS (Add lines5,6,7, S Ia.Ilb.1 lc.lid and lie) $ 6SD.0O $ 3.2VI.A 0 113) Disbursements 13a) Operating Expenditures (CRO-1310j $ JJ*.*3 1s 1*37 LS 13b) Contributions to Candidates/Political Committees (CRO-1310) s» ^ $ f c< 13c) Coordinated Party Expenditures (CRO-1310) s isi s C3 14) Aggregated Non-Media Expenditures (CRO-1315) s - 0 s 6> 15) Loan Repayments (CRO-1420) s 0 s tf «0 «"" 16) Refunds/Reimbursements from the Committee (CRO-1320) s _ p s - t^ ~ 17) In-Kind Contributions (CRO-1510) s, 0 * s - ^ 18) TOTAL EXPENDITURES (Add lines 13a. 13b. 13c. 14, 15, 16 and 17) s %5M.S3 s 1 a. 37.^5 19) Cash on Hand at End (Add lines4 and 12 together, (h sn subtract line 18] s Soog.35 $ 2*08.2*5 ^Dmo&aasera^ ::':-' -: ': 7^mm::,l +:} -v-'fe 5&S53^Igg^M-^s^gl 20) Non-Monetary Gifts Given to Other Committees (CRO-1330) $ *"~"» -» 21) OutstandingLoans (inch ones from othercampai ins) (CRO-1430) s tf.oo 22) Debts and Obligations owed by the Committee (CRO-1610) s c. 23) Debts and Obligations owed to the Committee (CRO-1620) s f - 24) Account Transfers Within the Committee (CRO-1720) s ^ 25) Administrative Support (CRO-1710) s t^ ' s - d> - 26) Forgiven Loans (CRO-1440) $ 4^J s ^«s> - 27) 48-Hour Notice Reports Sum (CRO-2220) 5; - >.- s 18) Contributions to be Refunded (CRO-1215) CRO-1100 NC State Board of Elections August 2008 ~ C - - C "

3 ;Araendraent ^. Contributions from Individuals pg L of^^idyes ETno Use this fonn to report individual contributions oyers50 or contributions under $50 ifform CRO 1205 is not used CRO-1210.III.HIIILIILUJ fe Sd.&o NC State Board ofelections April 2007

4 ,- ^Amendment Contributions from Individuals pg dl. of "2- O Yes ETna Use this form to report individual contributions over $50 orcontributions under $50 ifform CRO 1205 isnot used [J^ComiiutteeFniiName(andFandifappUcaM 2. ID Number J.sCtontributor.Jnfonnation:-:. Foil Name, Mailing Address & Phone (Include city, state, & zip) P.O. fit»c 7^7 /Add-...Remove - KeJ-ireJ c Employer's Name/Specific Field e. Election Snm to Date s, f. Prior g. Account Code h. Form of Payment I. In-Kind Description J. Date (mm/dd/yyyy) k. Amount o± CX^Ir J'3J'3o)2. <3oD.O O J:,ContributorInformation v<-., Fall Name, Mailing Address & Phone (include city, state,& zip) ;; /Add* ; : D.-Remove 3)S Qa.tr- if**) <3>i-?i><L_ Ki^is [A. «..//-; tj 7?<\-2*^6 :.Employer'sName/lpeciM Field TlexJl &f-*->rc* 5&TotaI of.alkcro-1210pajges^^^ ^»^vv;,-;v- :A CRO-1210 NC State Board ofelections s &5D.QQ j April 2007

5 . Amendment ^^ Disbursements ps /_ 0f _/_ D Yes OTno Use thisformto reportexpenditures from the committee for operating expenses, contributions to candidate/political cwrunitteesamkjootd^ rr. 1. Committee Full Name (ami Fund inapplicable) tuhk. >Lf M/WtJJ/ 0 AJ g 2. ID Number 3C$\H2 3. Type ofdisbursement (Please use separate CRO-1310 forms for each type ofdisbursement\ Cooperating Expenses Li Contributions to Candidates/Political Committees LI Coordinated Party Expenditures 4. Payee Information Add D Remove a. Full Name, Mailing Address & Phone (include city,state, & zip) b. Coordinated Committee Name SJLe-lh^, 71 jc 28ISL f. Accoont Code LL g. Form ofpayment C-h -c/c h. Purpose Code i. Date (mm/dd/yyyy) c Level Registered (Specify) LI Federal iycounty: State LJ Municipality: e. Election Sum to Date < -9-1*12 J. Amount $ 8*+$3 $ Joi/^s 2. k. Required Remarks PurAeA r~<slraj 4. Payee Information Foil Name, Mailing Address & Phone (inclnde dry, state, & zip) D Add D Remove b. Coordinated Committee Name c Level Registered (Specify) LI Federal Ljj State f. Acconnt Code g. Formof Payment rayme h. PurposeCode LDate(mm/dd/yyyy) j. Amonnt JUL Ck j4_ ujcbudty! LJ Municipality: * ^lc sg -3J-^oi2, %3P9^0 e. Election Sum to Date $ S7l, HS k. Required Remarks TDGT d-cl ^JL 4. Payee Information Add Remove. Foil Name, Mailing Address & Phone (include dry, state, & zip) b. Coordinated Committee Name c Level Registered (Specify) LJ Federal O County: L"j" State LJ Municipality: e. Election Sum to Date L Acconnt Code g. Formof Payment h. PurposeCode LDate(mm/dd/yyyy) j. Amount k. Required Remarks 5. Total only this Page 6. Total of ALL CRO-1310 Pages (This linegoes inline13aofdetailed Summary Page CRO-1100 ifoperating Expenses) (Thisline goesin line13b of DetailedSummary PageCRO-1100 if Contrib to Candidates/Political Comm) (ThisJme^oesmUne13c ofdetailedsummary Page CRO-1100 if Coordinated PartyExpenditures) 7.Purpose Codes (List detailed expenditure code in(h.) above) A* - Media E - Salaries Postage O* Other B* - Printing F* - Equipment J - Penalties C* - Fundraising G - Political Party K* - Office Expenses is ^xg-ps «5Vtf'?3 D - To Another Candidate H* - Holding Public Office Expenses Q* - Donation to Legal Expense Fond j^jodesrajnbredetoilg CRO-1310 NC State Board ofelections December2009

6 Amendment Outstanding Loans pg _J of J_ n Yes GHio Use this formto report any outstanding loans received duringa previousreportingperiod and until the loan is paid in full. 1. Committee Full Name (and Fund ifapplicable) 2. ID Number H U ~t cat osj -k, s- (-c u sst >* ^ OM^1' ** ' 3.-Lender Information. Full Name, Mailing Address & Phone (include city, state, & zip) Vr0.Rate <l % h. Security Pledged. Full Name of Lending Institution * &/<j<z. r.n-add-i'a-ipi Remove yens re-c) c. Employer's Name/Specific Field i. Original Loan Amount $ Pl.oo 3L(L&/f2~ e. Start Date (mm/dd/yyyy) 2~)3-2q}^l f. End Date (mm/dd/yyyy) '- 1-3 I3l j. Remaining Loan Balance $ u o o I. Loan Number \. Lender Information. Full Name, Mailing Address & Phone (Include city, state, & zip) /<;*>, s t\e ^*K t *, 1\<- 3.fJy6 Rate h. Security Pledged E Ic Full Name oflending Institution Remove KeT I t^a c Employer's Name/Specific Field l. Original Loan Amount $ /00.OO I e. Start Date (mm/dd/yyyy) J?-29^2 J2s L End Date (mm/dd/yyyy) /-J-So/3 j. Remaining Loan Balance $ /so. o o, Loan Number 3. Lender Information.. a. Full Name, Mailing Address & Phone (Indude city, state, & zip) H.Add.n.-. D Remove" I keys A«J~\oy^-c- M M NeTTi/*<-*( c. Employer's Name/Specific Field Rate h. Security Pledged L Original Loan Amount %. Full Name of Lending Institution $ *S/?o,oo e. Start Date (mm/dd/yyyy) S-an^Ao) f. End Date (mm/dd/yyyy) J~)'3di3 J. Remaining Loan Balance $ S0Q.0& L Loan Number ^ttotal^only^thisfpage^vr 5^Obtal/ofm^GROil430:P^es^^.v^^^:\a*X><-.y " :. -*(Thisone must be on lute 21ofDetailed'Summitry Page CR^l^H^^^-.i.-. CRO-1430 NC State Boaid ofelections $ 6^6.00 ^ *^-'g December 2007