4; Period End Date: -\} (mm/dd/yy) 9: Type ofreport. Municipal I I Organizational. Organizational. Thirty-five day. Pre-primary.

Transcription

1 I Amendment D Yes Usethis form for general report and committee information, mustbe signedand submitted along with other detailed forms. Do not use this form to update information -L CommitteeInformations 'ull Name Aj'cAjhJ /ra^klr >r ScJiool t <0c? b. Mailing Address (include City, State and Zip Code) 2; ReportJV/ear1:^,3^PenddvStart Date (mm/dd/yy),, <*W/ /d/jsmom 6. Type ofcommittee (CheclcOne), V J>^ Candidate Campaign Q] Party D PAC Referendum Expe^diSe1 Joint Fundraiser II LegalExpense Fund "Booster Fund" I I Building Fund Other: ^NumberofFundraisersthlsRepoft?^^ 1l^^co^CDiformatioii^^^Ci a.financial Institution Full Name f JAN CLEVELAND CO. BD. ELECTION TIME 4; Period End Date: -\} (mm/dd/yy) 9: Type ofreport Municipal I I Organizational I I Thirty-five day Pre-primary Pre-election Pre-runoff Semi-annual Final Special Mid Year Year End BY 5. Treasurer,Full Name c. ID Number / ScBpGfM d. Date Filed Quit( St APII e. Phone Number No 16*1-16 A-74 X* O{afu>0Jd Q. AllboTT (checkonly one type ofreportfrom one category) State/County D Organizational Quarterly First Second Third Fourth Semi-annual Mid Year Year End Final I I Special 11. Account Information a. Financial Institution Full Name Referendum I I I I Organizational Pre-referendum Final I I Supplemental Final II I I Annual Special 10;Special^pbrtJNa^rie b. Purpose c Account Code b. Purpose c Account Code 41 d. Period Begin Balance d. Period Begin Balance Mr-1 s CERTIFICATION I certify that the Committee or Fundis in compliance with all applicable provisions of Article 22A, 22B,& 22D-22M of Chapter 163 of thenc General Statutes and that no funds are commingled withprohibited or othernon-disclosed funds. I further certify that this report is complete, true and correctand that I have heen trainedby the NC StateBoardpfElections. FOR OFFICE USE ONLY Date Received: Date Postmarked: Date Scanned: Date Data Entered: Printed Name ofsigner JAN Employee: Employee: Employee: Employee: Delivery Method n Normal Mail Registered Mail H*^ Hand Delivered Electronically Filed Signer has not received mandatory training Please Note: This form cannot be used to amend committee information such asthe committee address, treasurer, assistant treasurer, custodian ofbooks information, or account information. Youmust amend the Statement of Organization (CRO-2100A-E) to makecommittee changes. CRO-1000 NC State Board ofelections August 2008

2 f n,-.h«\n Detailed Summary Use this form to summarize all disclosure reporting forms and to total monetary information. 1. Committee Full Name (and Fund if applicable) 2. Type ofreport 3. ID Number Kichsfd H&oKLr- for Scho* 1fooard Start of Election Cycle: January 1, crd/' Amendment Yes No 611 Lje.3^ BnJ ^tporl BChdCnH Total this Reporting Period Total this Election Cycle 4) Cash on Hand at Start 3^4.97 S co RECEIPTS 5) Aggregated Contributions from Individuals (CRO-1205) % S /^5~ 6) Contributions from Individuals (CRO-1210) / 0 //90* 7) Contributions from Political Party Committees (CRO-1220) s 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 s s ". -.' * 7.5X6*- s ',*r^ 11a) Interest on Bank Accounts (CRO-1250) s lib) Contributions from Not-for-Profit Organizations (CRO-1250) s lie) Outside Sources of Income (CRO-1250) s s lid) Legal Expense Fund - Other Sources (CRO-1270) lie) Exempt Purchase Price Sales (CRO-1265) s 12) TOTAL RECEIPTS (Add lines 5, 6, 7, 8, 9, 10, 11a, lib, lie, 1Idand He) EXPENDITURES 13) Disbursements 13a) Operating Expenditures (CRO-1310) < t &(,<* s 873cZ^ 13b) Contributions to Candidates/Political Committees (CRO-1310) s % 13c) Coordinated Party Expenditures (CRO-1310) s 14) Aggregated Non-Media Expenditures (CRO-1315) 15) Loan Repayments (CRO-1420) 16) Refunds/Reimbursements From the Committee (CRO-1320) 17) In-Kind Contributions (CRO-1510) s /4#» s /ffli* 18) TOTAL EXPENDITURES (Add lines 13a, 13b, 13c. 14, 15, 16and 17) 19) Cash on Hand at End (Add lines 4 and12together, then subtract line 18) o O ADDITIONAL INFORMATION 20) Non-Monetary Gifts Given to Other Committees (CRO-1330) 21) Outstanding Loans (incl. ones from other campaigns) (CRO-1430) 0-22) 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) s '25) Administrative Support (CRO-1710) 26) Forgiven Loans (CRO-1440) 27) 48-Hour Notice Reports Sum (CRO-2200) 7,^ i 7.46/^ y s ' 28) Contributions to be Refunded (CRO-1215) CRO-1100 NC State Board of Elections Ausust2008

3 Contributions from Individuals» Pe / op-l Amendment nzino Use this form to report individual contributions over 50 or contributions under 50 ifform CRO 1205 is not usee! 1. Committee Full Name (and Fund ifapplicable) 2. ID Number /<,/ca<3f</ rrtcklir for (School >aarj Sc&scjy 3. Contributor Information Add Remove "7>0. l *w. /<&W b. Job Title/Profession Employer's Name/Specific Field d. Comments dawpajqn e. Election Sum to Date */? f. Prior g. Account Code h. Form ofpayment i. In-Kind Description j. Date (mm/dd/yyyy) k. Amount 61 Chick ///0&/26II fo/i % /oo 3. Contributor Information Add Remove b. Job Title/Profession d. Comments c. Employer's Name/Specific Field e. Election Sum to Date f. Prior g. Account Code h. Form ofpayment i. In-Kind Description {. Date (mm/dd/yyyy) k. Amount 3. Contributor Information Add Remove b. Job Title/Profession d. Comments c. Employer's Name/Specific Field e. Election Sum to Date f. Prior g. Account Code b. Form ofpayment i. In-Kind Description {. Date (mm/dd/yyyy) k. Amount 4. Total only this Page 5. Total ofall CRO-1210 Pages (This line mustbe on line 6 ofdetailedsummary Page CRO-1100) CRO-1210 NC State Board of Elections s /OO /J6 - April 2007

4 f.. I a k I <-i ~» *, / - Amendment Disbursements JAN ^ / 2012 ps - of cx Q ycs Use this form to report expenditures from the committee for; operating expenses, contributions to candidate/political committeesand coordinated party expenditures. 1. Committee Full Name (and Fund if applicable) 2. ID Number /*</ chsr-j /-/-aofke-f- -f-'or Sch<a<=>/ ^arc/ c3cb>3gm 3. Type ofdisbursement (Please use separate CRO-1310 forms for each tvpe ofdisbursetit ml) ' t_j Operating Expenses J Contributions tocardidatcs/political Committees [! Coc rdinated Party Expenditures 4. Payee Information L J Add (_] Remove (include citv, state, & zip) ~77Tt Ulds CorptrMjo* JshLv.lU, NC c2s&0^ b. Coordinated Committee Name d. Comments c. Level Registered (Specify) Federal [J County: Li State! I Municipality: e. Election Sum to Date Sc%,7J5- f. Account Code g. Form ofpayment h. Purpose Code i. Date (mm/dd/yyyy) j. Amount k. Required Remarks No 61 Ch&ck / m/m/wii tfol*l MsrcdrJ Y-ijil/nc, 4. PayeeInformation! j Add 1 I Remove (include citv, state. & zip) % b. Coordinated Committee Name d. Comments UJh^iz Up Shopp^r- /6eO^ Ejsl Church S&C-dc. Level Registered (Specify) i Federal 1 County: i State I Municipality: e. Election Sum to Date 1 %ea0o* f. Account Code g. Form of Payment h. Purpose Code i. Date (mm/dd/yyyy) j. Amount k. Required Remarks 61 Chuck ft Jl/0 /M)lf %d60- fcdio - UiOUs M t 4. Payee Information Add!_J Remove (include citv, state, & zip) // 1CS a/ (JJrCon &C *136 b. Coordinated Committee Name d. Comments c. Level Registered (Specify) j Federal 1 ] County: I State fj Municipality: e. Election Sum to Date ^ T6 f. Account Code g. Form of Payment h. Purpose Code i. Date (mm/dd/yyyy) j. Amount k. Required Remarks d Chick A ll/ot/zoll %Jtsu*- fa//* 4/ 5. Total only this Page S A&T7. OO 6. Total ofall CRO-1310 Pages (This line goes in line 13a ofdetailedsummary Page CRO-1100 ifoperating Expenses) (This line goes in line 13b ofdetailedsummary Page CRO-1100 ifcontrib to Candidates/Politictxl Comm) (This linegoes in line 13c ofdetailedsummary Page CRO-1100 ifcoordinatedpart}' Expenditu res) 7.Purpose Codes (List detailed expenditure code in (h.) above) A*-Media B* - Printing C* - Fundraising E - Salaries F* - Equipment G - Politic al Party I - Postage J - Penalties K* - Office Expenses 0* - Other * Codes require detailed explanation in required re m.irks field (k) %A,8(>uu* D - To Another Candidate H* - Holding Public Office Expenses Q* - Donatiori to Legal Expense Fund CRO-1310 NC State Board of Elections December 2009

5 IA t t r\ -*i *n Amendment Disbursements JAN 2 / 2012 pg &L «* <p\_ D yes Use this form to report expendituresfrom the committee for; operatingexpenses, contributionsto candidate/political committees and coordinatedparty expenditures. 1. Committee Full Name (and Fund ifapplicable) 2. ID Number ACZK&^VA R/rzh**/ Ubfik-LT -Ur^chtal ^tar J 3. Type ofdisbursement (Please use separatecro-1310 formsfar each typeofdisbursement.) fur* operating Expenses p~ Contributions to Candidates/Political Committees j Coordinated Party Expenditures 4. Payee Information Add f~l Remove ~77w Shi-lbd S/jr Shelby, NC <ZS/<s-c f. Account Code g. Form ofpayment 61 Chick 61 Check 4. Payee Information (Include city, state, & zip) '^P^tClTSKtrx^l 1)6 Ch*-rnJvilll~&1- h. Purpose Code b. Coordinated Committee Name S c."level Registered(Specify) 1 r^i "" "~"_~.". r^-i ' " u heaerai j_j UKaty:! i! State! j Municioalftv: d. Comments e. Election Sum to Date» 666- rpascloac i.date (mm/dd/yyyy) j.aunmal j k.required Keiaarks A Nucll \bj<wu lltch j-^ 'ihue11 V/lS^Vfharl (L! t i / ; T~I I it D Add [_ Remove b. Coordinated Committee Name vel Registered (Specify) Federal Stsie County: Ivfur.icipaiity: f. Account Code g.form ofpayment b. Pnrpose Code I j.bate(mni/dd/yyyy) j. Amount 01 Chick d. Comments f t. Election Sum to Date s J/f<? 2- k. Required Remarks No AJ 4. Payee Information a. Full Name, Mailing Address & Pbone Remove b. Coordinated Committee Name <LComments /3ZL ^s+uorl*n l^f c. Level Registered (Specify) u u Federal State D County: Municipality: f. Account Code (g. Form ofpayment I fa. Pm-pose Code ' Jj.pate(mni/dd/yvyy) j. Amount e. Election Sum to Date.a/5"' Jo fe. Required Remarks Ol I Chtck O j nm*6it js^-y \7&h*..C2(fc.- x. 5. Total only this Page 6. Total ofall CRO-1310 Pages (This line goes in line 13a ofdetailedsummary Page CRO-1100 ifoperating Expenses) (This line goes in Bne 13b ofdetailedsummary Page CRO-llOQ ifcontrib to Candhfates/paitfcai Comm) (This ling &oes in Hue 13c o^detailedsummer"pp c CP.^J-liQV /'' Cocrdindsd Ports.' E^y^Ttdltit*i*c- 7. Purpose Codes (List detailed expenditure code in (h.) above) A* - Media «-/" - j r»r»'.iji«c* - Fundraismg <> -t-..:.. - : / >(09.O>'z -5" s^.s^ y.%.".en..?-..,.. /»* _ r\iu.-..- Codes require detailed explanation in required remarks field (k) X.<Y«f«* t4rt«'tr*'f fi# i^wwuvwt A#Ww^

6 Loan Proceeds JAN Use this form to report proceeds from a loan and loan endorser's information Alojjrrgroceeds^ta^^ SJtSiMe^giM ^^/cafrj//tabs' for ScA<*>/ IS*^^ aamtfg^siswffib^^ a. Full Name,Mailing Address & Phone pg Amendment L*&\ C\ JP Yes EZf No b. Job Title/Profession d. Comments -/ c. Employer's Name/Specific Field 7W~6JJI- 7B40 g.rate I Full Name, oflendingttstitution i. AccountCode ' j. Form ofpayment ol GhLcJL * /,500ss-. Full Name, Mailing Address & Phone (Include city, state, & zip) WMW^^M^W^M^^^^^mM^MMMM^ b. Job Title/Profession c Employer'sName/Specific Field / fj/a z^\ d. Percentage e. Amount' a. Full Nome, Mailing Address& Phone b. Job Title/Profession c Employer's Name/Specific Field d. Percentage e. Amount a. Full Name* Mailing Address & Phone (includecity, state, & zip) b. Job Title/Profession c. Employer's Name/Specific Field d. Percentage e. Amount a.foil Name, Mailing Address & Vhoue (include dty, state, & zip) b. Job Title/Profession & Employer's NamertSperificField d. Percentage e.amount

7 AM 0? v 2?' 2012 Loan Proceeds Use this form to report proceeds from a loan and loan endorser's information A loan proceeds statement must accompany each loan that is from an individual 1. Committee Foil Name (and Fund ifapplicable),lender Information: ^^ e^ ''' n Add Remove Remov< (include dry, state, & zip) *char-d HAork*r Jr. g. Rate h. Security Pledged 0 * A^4 I.Full Name of Lending Institution ajm 4. Endorsers/Makers (Thepeople whoguarantee theloan.) (tndude city, state, & zip) N A b. Job Title/Profession ~L>fr-e_cSLor fj /j Amendment Pg ^ of &\ QYes Q^No c Employer's Name/Specific Fidd "BosmtSS 2. ID Number 6CB8GM d. Comments 5*jL6 n e. Start Date (mm/dd/yyyy) /^^/W7 f. End Date (mm/dd/yyyy) </A*/ i. Account Code j. Form of Payment k. Amount 0) /rjnsht-r s/-i. b. Job Title/Profession d. Percentage /v/a ZOIZL */,asz>**- m. Loan Number A//A c Employer's Name/Specific Fidd a/> e. Amount b. Job Title/Profession c Employer's Name/Specific Field (include dty, state, & zip) d. Percentage b. Job Title/Profession e. Amount c Employer's Name/Specific Field (indude dty, state, & zip) d. Percentage b. Job Title/Profession e. Amount c Employer's Name/Specific Field <L Percentage e. Amount 15. Total ofall CRO-1410 Pages (Tins linemust beonlike9 ofdetailed Summary PageCRO-1100) CRO-1410 NC State BoardofElections»0^530^ April 2007

8 JAN Loan Proceeds Statement The individual making a loan to the committee must provide the following information. Failure to provide all of the information requested could be a violation of campaign reporting disclosure laws. V-Nanfie of committee to receive loan: Kfcnar-d htc>6<it -h** School.Htara! Person lending money to committee (Lender): Date of loan to committee: /*/&&/ czoi 7 Name of lending institution and account number (source): MM Amount of loan: ^ // Ow d<s Names of all parties responsible for payment of loan (guarantors): nia Period of loan: /6/&8/cl6fl - /6/<ZS/<%&/. Rate of interest of loan: Security pledged for loan: A/s'A I, ;<?/73ra' rrfiok&r,jr.,acknowledge that all of the information (Person lending money to committee) provided is complete, true, and accurate. I further understand I may not forgive a loan that has an outstanding balance to any source. Wi^^i^^i- Signature olf Lender [/-)* ft ^^^ycto^tju r Signature of Treasurer of Committee / -This form must be submitted with the disclosure report for which the loan is initially disclosed. jp^ CRO-6100 Loan Proceeds Statement July 2007

9 JAN Loan Proceeds Statement The individual making a loan to the committee must provide the following information. Failure to provide all of the information requested could be a violation of campaign reporting disclosure laws. Name of committee to receive loan: ~/z?ic/i<3rc/ /-Tdok-Lr-for (School ^P\6<3rd -fe* 7 Person lending money to committee (Lender): 7^/cAjtrJ /t>oatr (If Date of loan to committee: ir. ///cz/c20// / / Name ieopf lending institution and account number (source): AL Amount unc of loan: ^/ <?ffz> Names les of all parties responsible for payment of loan (guarantors): A//A 9 Period of loan: '/*./&// - ///a/* <Z4/<Z Rate of interest of loan: Security pledged for loan: j* r /t/a i. A/cA^rd' /JoahrJh _, acknowledge that all of the information (Person lending money to committee) provided is complete, true, and accurate. I further understand I may not forgive a loan that has an outstanding balance tefany source. Signature of Lender Signature of Treasurer of Committee This form must be submitted with the disclosure report for which the loan is initially disclosed. CRO-6100 Loan Proceeds Statement July 2007

10 JAN Loan Repayments Amendment / Pg / of _!_.. Yes No Use this form to report payments on an existing loan. J lveommitteefuh Name(and Fund if apph^ >, 2. ID Number j^c/ardr/toklf ft>r Sc/ioo/ Qo3j-J 3.LenderInformaffenf^fr^V**'^'-,! " - Add n Remove ShjUb-i, Ale czbl^z- 70*1-L?z-76^0 ScBQc^rA b. Comments fvnjs ttij-u r-ifi&j fodn! i c Original Loan Date /'/a/<zo// d. Original Loan Amount /y ^5Z> e. Remaining Loan Balance f. Account Code g. Form ofpayment h. Date (mm/dd/yyyy) i. Repayment Amount» 96/* 0/ 6//<Z4/ZOl /*#** / 3.LenderInformational,^, t^b*^^ '"-. Q ' Add.-',, Remove * * b. Comments c Original Loan Date A d. Original Loan Amount e. Remaining Loan Balance f. Account Code g. Form ofpayment h. Date (mm/dd/yyyy) i. Repayment Amount 3.LenderInformation^ V"*;v\^ / :' V - Add - *Q Remove t. b. Comments c Original Loan Date d. Original Loan Amount e. Remaining Loan Balance f. Account Code g. Form ofpayment h. Date (mm/dd/yyyy) i. Repayment Amount 4. Total only this Page'"?;// r ' * /z/ ** 5. Total ofall CRO-1420 Pages, (This line must be on line ISofDetailedSummaryPage CRO-1100) * /46~ CRO-1420 NC State Board ofelections December 2007

11 JAN )2 Forgiven Loans pg /~n {Amendment of S S_ jd Yes. CI Use this form to report any loan which has been forgiven by the lender. A Forgiven loan statement (CRO-6200') must accompany each forgiven loan. 1. CommitteeFull Name (and Fund ifapplicable) 2.mNunmefe;^ /j/ca^r-j r/afiktr- ft>r,^^^/ fjcard 3. Lender Information Q'Add-T, Remove. /<51ZO Kinej jd*4jnur Covr-/- b. Comments Sc&aqM 5" /Loans U*J«- (*&) c Original Loan Date (mm/dd/yyyy) 0*7/fid/. 0/1 Z>0 3. Lender Information^ Add-.' D Remove ~~?;chss-j <LboLur- Jr. * soo**- -/- f. Election Sum to Date 7,5157) d. Original Loan Amount g. Date (mm/dd/yyyy) soo M/3jMm e. Remaining Loan Balance h. Forgiven Amount b. Comments 6"~/Loans //g«4 (**ZJ c Original Loan Date (mm/dd/yyyy) 6<!/6&/SLO/t d. Original Loan Amount. <2jSZ>o**- y f. Election Sum to Date 7, est) g. Date (nun/dd/vyyy) /WAW// e. Remaining Loan Balance h. Forgiven Amount *, 5Z> > <, s~o&^ 3; Lender Information"^ U Addv~ _ Remove ShU^>^t NC ^B/S^L 704-6>9# : Total only this Page 5. Total ofallicro-1440 Pages (Tliis line must be on line 26 ofdetailed Summary Page CRO-llOQ) - b. Comments JL&zns Mad*. G*=3J c Original Loan Date/mm/dd/yyyy) /A//t/i20lt d. Original Loan Amount * ol.oco'-*- 'j. e. Remaining Loan Balance cz.ooo2^ The lender information shouldcontain the same information as suppliedon the originalloan proceedstatement. f. Election Sum to Date 7 SS-Q g. Date (mm/dd/vyyy) /a/3//<zo// h. Forgiven Amount *<3,ooo a* * "7, HOI- CRO-1440 NC State Board of Elections December 2007

12 JAN Forgiven Loans Use this form to report any loan which has been forgiven by the lender. a. FullName, Mailing Address & Phone (include city, state, &,zip) ttchajrd iaok-ur Jr ShJUb^, /be <&'<&- 7#V- u^^'imo Lt>&ns c Original Loan Date (rara/dd/yyyy) /t/ze/c<z6/t d. Original LoanAmount s /j&>0 Ude- (^4j f. Election Sum to Date * 7,^5^ g. Date (mm/dd/yyyy)" /2/3i/eL >// e. Remaining Loan Balance h. Forgiven Amount / SV0 * / s~ao ^~ ^^^^^M^^^Ait^g^SJ^^^ShC^^MJM^i&^^S&MM'B^^^^Mi, (inciode city, state, & zip) IToUO /On-j Ar^r Court J/0%, A^ ^^ y^v- ^f^-^6 3BSKg»E^iraiSiMBm^^ (fadude cfty, state, & zip) b. Comments. s~ A^s //*/*. C^^FS cvoriginall^ndatel^ f. Election Sum to Date /j/ta/czo/i V- d. Original Loan Amount» /,0SZ> e.remaining LoanBalance» /^SZ)*8- b. Comments tfstsz? g.date iyb (nim/dd/yyyy) J^f/o< >// h. Forgiven Amount #v "53" >~^v»"ag/<'"''"?jv^>'^'v ^T^-^^^^-y-^ (^Original Loan Date (mm/dd/yyyy) f. ElectionSum to Date d. Original Loan Amount g. Date(mm/dd/yyyy) & Remaining Loan Balance h. Forgiven Amount m *» c?. HCf!*- 7^/^ JYie lenderinformation shouldcontainttw sameinformationas supplied on theoriginalloanproceedstatement CRO-1440 NC State Board ofelections December2007

13 Jf* JAH 2 7 2QV Kimberly Westbrook-Strach Deputy Director Campaign Reporting North Carolina State Board ofelections 506 N Harrington Street Raleigh, NC MailingAddress PO Box Raleigh, NC (919) Fax: (919) Forgiven Loan Statement This form is used to report a loan that has been forgiven by the lender. The lender's signature is required on this form and it must accompany the next filed report a^< / / // / / Name of Lender: Committee receiving \ym\4r;<jijr-j ri^ko- <&/* Date of loan: 7/*/ 6f/ Amount of originai ioan: ^"TZfc) <& 'Amount of ioan to be forgiven:,szfc2 ' W?<W tk&ard I. i, /> J\icJtsrd tcft&fd UteJur ftfe/ci-r <Jr.. do not wish to be reimbursed for the amount of the loan indicated above* and will consider the amount loaned a contribution to the committee. I understand and confirm no other parties are responsible for payment of this loan. may not forgive a loan for which there is an outstanding balance owed to any source. I Signature of Lender _(.4. Jr. r~?*< r^jusuwa; <' \ v.._- Signature of Committee Treasurer / /) Note: This Statement is to be filed with the Election Board where the committee's reports are filed. CRO-6200 Forgiven Loan Statement June 2007

14 JAU Kimberly Westbrook-Strach Deputy Director CampaignReporting 0 North Carolina State Board ofelections 506 N Harrington Street Raleigh, NC Mailing Address PO Box Raleigh, NC (919) Fax: (919) Forgiven Loan Statement This form is used to report a loan that has been forgiven by the lender. The lender's signature is required on this form and it must accompany the next filed report Name of Lender: ;x/g/y/v/ n&a/clt, jr. Committee receiving loan: jp;*jijrdm&jr&r- ^r. )ejio*/ J^a4ra/ / / * / Pate of loan: 1/4/ 6// Amount of original ioan: ^>;, 5T6 (3d <&& *Amount of loan to be forgiven: *&?, ~D > 1P> l i Jj! r I. f\tc.n3r& frtek&t Jr.. do not wish to be reimbursed for the amount of the loan indicated above* and will consider the amount loaned a contribution to the committee. I understand and confirm no other parties are responsible for payment of this loan. may not forgive a loan for which there is an outstanding balance owed to any source. I Signature of Lender -J ^ - '/? hi a-a- Signature of Committee Treasurer / Note: This Statement is to be filed with the Election Board where the committee's reports are filed. CRO-6200 Forgiven Loan Statement June 2007

15 m 2720i2 Kimberly Westbrook-Strach Deputy Director CampaignReporting North Carolina State Board ofelections 506N Harrington Street Raleigh, NC MailingAddress PO Box Raleigh, NC (919) Fax: (919) Forgiven Loan Statement This form is used to report a loan that has been forgiven by the lender. The lender's signature is required on this form and it must accompany the next filed report Name of Lender:.// Ann3rd /i'## ir Jr. Committee receiving XvwtJPfcAji'tf Jr**hr 4V,<\eA*a/.r^srd Date of loan: /*//// <&6tf 4 4 A* ^_ <2 & Amount of original loan: acj, O60 'Amount of loan to be forgiven: &<. 30 && J r j f J / tcn3ra rrfejcej- Jr. do not wish to be reimbursed for the amount of the loan indicated above* and will consider the amount loaned a contribution to the committee. I understand and confirm no other parties are responsible for payment of this loan. may not forgive a loan for which there is an outstanding balance owed to any source. I Signature of Lender Signature of Committee Treasurer ' Note: This Statement is to be filed with the Election Board where the committee's reports are filed. CRO-6200 Forgiven Loan Statement June 2007

16 wmmk JAM 2? 2012 Kimberly Westbrook-Strach Deputy Director Campaign Reporting North Carolina State Board ofelections 506 N HarringtonStreet Raleigh, NC MailingAddress PO Box Raleigh, NC (919) Fas: (919) Forgiven Loan Statement This form is used to report a loan that has been forgiven by the lender. The lender's signature is required on this form and it must accompany the next filed report r Name of Lender: AI'fAcfrc/' rvafialf Jr. Committee receiving \om^/t*/rjr</ //aextr -Qy Sch&&! Rtaral Date of loan: /tfe8/&6f/ Amount of original ioan: */, SV(3 ~ *Amount of loan to be forgiven: */, ~&6 ^ IP? L J It t ( I. s\tc/l&ra f?6k&t <jr. do not wish to be reimbursed for the amount of the loan indicated above* and will consider the amount loaned a contribution to the committee. I understand and confirm no other parties are responsible for payment of this loan. may not forgive a loan for which there is an outstanding balance owed to any source. I Signature of Lender U^ TJ-V r~ w Signature of Committee Treasurer / JU&f Note: This Statement is to be filed with the Election Boardwhere the committee's reports are filed. L CRO-6200 Forgiven Loan Statement June 2007

17 JAN 2? 2012 KimberlyWestbrook-Strach Deputy Director - Campaign Reporting North Carolina State Board of Elections 506 N HarringtonStreet Raleigh, NC MailingAddress PO Box Raleigh, NC (919) Fax: (919) Forgiven Loan Statement This form is used toreport a loan that has been forgiven bythe lender. The lender's signature is required on this form and it must accompany the next filed report Name of Lender: /^I'chzr-J /iooke-r J{ Committee receiving loan: 7?/<?harJrttokit Anr ScAoo/ ftgdrd Date of loan: ~7 T Amount of original loan: % 4<ro " M *Amount of loan to be forgiven: i. AJchzt-J /i^kf kh?6l UB r. do not wish to be reimbursed for the amount of the loan indicated above* and will consider the amount loaned a contribution to the committee. I understand and confirm no other parties are responsible for payment of this loan. I may notforgive a loan for which there is an outstanding balance owed to any source. Signature of Lender Signature of Committee-Treasurer Note: This Statement is to be filed with the Election Board where the committee's reports are filed. CRO-6200 Forgiven Loan Statement June 2007