Disclosure Report Cover Ycs m 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 b. Mailing Address (include City, State and Zip Code) 403 WEST MOUNTAIN STREET KINGS MOUNTAIN, NC 28086 d. Date Filed I0l27)l\ e. Phone Number (704) 739-0806 2. Report Year 3. Period Start Date (mm/dd/yy) 4. Period End Date (mm/dd/yy) 5. Treasurer Full Name 2011 09/28/2011 10/24/201 LARRY DEAN HAMRICK JR 6. Type of Committee (Check One) PQ Candidate Campaign Party ~1 Joint Fundraiser PAC ) ] Referendum j~~] Legal Expense Fund 7. Typeof Fund (ifapplicable, check one) I ] "Booster Fund" p] Building Fund r] Presidential Election YearCandidates Fund i ] NC Public Campaign Financing Fund Other: 8. Number of Fundraisers this Report 0 9. Type of Report (check only one type ofreport from one category) Municipal EI Organizational Thirty-five day Pre-primary Pre-election Prc-runolT Semi-annual Final Special Mid Year Year End State/County r~1 Organizational Quarterly First Second Third Fourth Semi-annual fj Final Ll Special Mid Year Year End Referendum ~ Organizational i~] Pre-referendum Final ~1 Supplemental Final P] Annual I-] Special 10. Special Report Name PRE-ELECTION REPORT 3. Account Information 3. Account Information a. Financial Institution Full Name a. Financial Institution Full Name WACHOVIA b. Purpose c. Account Code b. Purpose c. Account Code ELECTION d. Period Begin Balance d. Period Begin Balance s Z \?.IC CERTIFICATION I certify that the Committee or Fund is in compliance with all applicable provisions ofarticle 22A, 22B & 22D-22M of Chapter 163 ofthenc General Statutes and that no funds are commingled with prohibited or other non-disclosed funds. I furthercertify that this report is complete, true andco/fectand tha\ I have been trained by the NC State Board Printed Name of Signer FOR OFFICE USEONLY Date Received: Date Postmarked: Date Scanned: 0CJ28MI 10/26/201 Date Delivery Method Normal Mail Registered Mail GKHand Delivered Electronically Filed f~l Signer has not received Date Data Entered: mandatory 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. You must amend the Statement oforganization (CRO-2100A-E) to make committee changes. CRO-1000 NC State Board of Flections December 2007
Detailed Summary Yes El No Use this form to summarize all disclosure reporting forms a id to total monetary information 1. Committee Full Name (and Fund ifapplicable) 2. Type of Report 3. ID Number Vris-d&chor\ Report Start ofelection Cycle: January 1, 2011 Total this Reporting Period Total this Election Cycle 4) Cash on Hand at Start S 298.10 S 0.00 RECEIPTS 5) Aggregated Contributions from Individuals (CRO-1205) S 0.00 S o.oc 6) Contributions from Individuals (CRO-1210) s 100.00 $ /Y2A.CO 7) Contributions from Political Party Committees (CRO-1220) $ 0.00 s 0.00 8) Contributions from Other Political Committees (CRO-I230) $ 0.00 $ 0.00 9) Loan Proceeds (CRO-1410) $ 0.00 s 500.00 10) Refunds/Reimbursements to the Committee (CRO-1240) s 0.00 s 0.00 11) Other Receipt Sources 1la) Interest on Bank Accounts (CRO-1250) s 0.00 s 0.00 lib) Contributions from Not-For-Profit Organizations (CRO-1250) $ 0.00 $ 0.00 lie) Outside Sources of Income (CRO-1250) $ 0.00 $ 0.00 lid) Legal Expense Fund- Other Sources (CRO-1270) $ 0.00 $ 0.00 lie) Exempt Purchase Price Sales (CRO-1265) $ 0.00 $ 0.00 12) TOTAL RECEIPTS (Add lines 5.6, 7. 8, 9,10,11 a,1lb,l lc lid and lie) $ 100.00 $ 1,920.00 EXPENDITURES 13) Disbursements 13a) Operating Expenditures (CRO-1310) $ 325.53 $ 1,729.43 13b) Contributions to Candidates/Political Committees (CRO-J310) $ 0.00 $ 0.00 13c) Coordinated Party Expenditures (CRO-1310) $ 0.00 $ 0.00 14) Aggregated Non-Media Expenditures (CRO-1315) $ 43.78 $ 61.78 15) Loan Repayments (CRO-1420) s 0.00 $ 0.00 16) Refunds/Reimbursements from the Committee 17) In-Kind Contributions (CRO-1320) (CRO-1510) $ 0.00 $ 0.00 s 0.00 $ 100.00 18) TOTAL EXPENDITURES (Add lines 13a. 13b. 13c. 14. 1:, 16 and 17) s 369.31 $ 1,891.21 19) Cash on Handat End(Add lines 4 and 12 together, then subtract line 18) $ 28.79 $ 28.79 ADDITIONAL INFORMATION 10) Non-Monetary Gifts Given to Other Committees (CRO-1330) s 0.00 11) Outstanding Loans (incl.ones from other campaigns) (CRO-1430) $ 500.00 12) Debts and Obligations owed by the Committee (CRO-1610) $ 0.00 13) Debts and Obligations owed to the Committee 14) Account Transfers Within the Committee (CRO-1620) (CRO-1720) $ 0.00 $ 0.00 15) Administrative Support (CRO-1710) $ 0.00 s 0.00 16) Forgiven Loans (CRO-1440) s 0.00 $ 0.00 11) 48-Hour Notice Reports Sum (CRO-2220) $ 0.00 s 0.00 J8) Contributions to be Refunded (CRO-1215) $ 0.00 $ 0.00 CRO-1100 NC State Board of Elections August 2008 OCfTf28011
Contributions from Individuals Pg of Yes H No Use this form to report in dividual contributions over $50 or contributions under$50 ifformcro 1205 is not used I. Committee Full Name (and Fund ifapplicable) 2. ID Number 1 3. Contributor Information IE! Add Remove KRIS THOMPSON 170 HARBOR POINT DRIVE CHERRYVILLE, NC 28021 b. Job Title/Profession d. Comments DIRECTOR c. Employer's Name/Specific Field PEAK RESOURCES c. Election Sum to Date s 100.00 f. Prior g. Account Code h. Form of Payment i. In-Kind Description j. Date (mm/dd/yyyy) Iv. Amount 01 Check 09/29/2011 $ 100.00 $ $ 4. Total only this Page $ 100.00 5. Total ofall CRO-1210 Pages (This line must be on line 6 ofdetailed Summary Page CRO-llOO) $ 100.00 CRO-1210 NC State Board of Elections April 2007 OCT 2 8 2011
Disbursements pg \_ 0f i_ D Yes El no Use this formto report expenditures fromthe committee for operating expenses, contributions to candidate/political committees and coordinated party expenditures 1. Committee Full Name (and Fund if applicable) 2. ID Number UUU-^CBX56-0-0UU 3. Type of Disbursement (Please use separate CRO-1310 forms for each type ofdisbursement.) EI Operating Expenses IH Contributions to Candidates/Political Committees Coordinated Party Expenditures 4. Payee Information 4 ALL PROMOS 40 MAIN STREET CENTERBROOK, CT 06409 Add Remove b. Coordinated Committee Name d. Comments c. Level Registered (Specify) ' Federal 13 County: State r~l Municipality e. Election Sum to Date 228.27 f. Account Code g. Form of Payment 01 Debit Card h. Purpose Code B i. Date (mm/dd/yyyy) j. Amount k. Required Remarks 10/14/20 14.11 HANDOUT PENS 4. Payee Information THE UPS STORE 1161 EAST MARION STREET SHELBY, NC 28150 Add Remove b. Coordinated Committee Name d. Comments c. Level Registered (Specify) Federal El County: State Municipality: c. Election Sum to Date $ 255.20 f. Account Code g. Form of Payment h. Purpose Code i. Date (mm/dd/yyyy) j. Amount k. Required Remarks 01 Debit Card 15 i0/18/201 211.42 HAND OUT CARDS 5. Total only this Page 325.53 6. Total of ALLCRO-1310 Pages (Thislinegoes in line 13a ofdetailedsummary Page CRO-llOO if Operating Expenses) (This linegoes in line 13b ofdetailed Summary PageCRO-llOO ifcontrib to Candidates/Political Comm) (This linegoesin line 13c of Detailed Summary Page CRO-llOO if Coordinated Party Expenditures) 7.Purpose Codes A*-Media B* - Printing E - Salaries F* - Equipment I - Postage J - Penalties (List detailed expenditure code in (h.) above) C* - Fundraising G - Political Party K* - Office Expenses 325.53 D - To Another Candidate H* - Holding Public Office Expenses Q* - Donation to Legal Expense Fund * ther * Codes require detailed explanation in required remarks field(k) CRO-1310 NC State Board of Elections December 2009 OCT 2 8 2011
Aggregated Non-Media Expenditures Optional form used to report NC Non-Media Expenditures of $50 or less. 1. Committee Full Name (and Fund ifapplicable) page of 2. ID Number Yes El No 3. Payee Information a. Amend b. Account Code c. Form of Payment d. Purpose Code e. Date (mm/dd/yyyy) f. Amount E~J Add 01 Debit Card B 10/11/20 $ n Rer 7.48 Add Debit Card 10/21/20 Rem 36.30 4. Total only this Page 5. Total ofall CRO-1315 Pages (This line must be on line 14 ofdetailed Summan> Page CRO-llOO) urpose Codes (List detailed expenditure code iii(d) above) B* - Printing F* - Equipment E - Salaries I - Postage C* - Fundraising G - Political Party K* - Office Expenses J - Penalties O*- Other * Codes require detailed explanation in required remarks field (g) g. Required Remarks HAND OUT CARDS HAND OUT CARDS 43.78 43.78 P - To Another Candidate H* - Holding Public Office Expenses Q* - Donations to Legal Expense Fund CRO-1315 NC Slate Board of Hlcctions December 2009 0CT2 8M11
Outstanding Loans pg _ r _i_ Yes S No Use this fonnto report any outstanding loans received during a previous reporting period and until the loan is paid in full. 1. Committee Full Name (and Fund ifapplicable) 2. ID Number 3. Lender Information Add Remove SHEARRA MILLER 403 WEST MOUNTAIN STREET KINGS MOUNTAIN, NC 28086 1). Job 'Iltlc/Profession d. Comments i^cuve ^reci^ c. Employer's Name/Specific Field e. Start Date (mm/dd/yyyy) 07/13/2011 f. End Date (mm/dd/yyyy) g. Rate h. Security Pledged i. Original Loan Amount j. Remaining Loan Balance 0 % CASH $ 500.00 $ 500.00 k. Full Name of Lending Institution 1. Loan Number 4. Total only this Page S 500.00 5. Total ofall CRO-1430 Pages (This line must be on line 21 ofdetailed Summary Page CRO-1100) S 500.00 CRO-1430 NC State Board ofelections December 2007,,;