COPY Disclosure Report Cover oe" et Use this form for peneral report and committe information, must be signed and submited along with other detsted forms De not use tis form to update information, Committe Information Tbemy Claris se Gly Cosel fo Natng Adards Grate City, Sead Zip Codd) 1329 (elec Gorden be Ralugt swe 27663 [=1D Number fron ne tanga “Cnc Compa gn ET = strfCount [Referendum I xc TD eeeston prin [Topics I tcerentenExpentire Eoin Fndcases TE] Thin te aay Quy ID Peet tee Expense rns ED brian tm ra fre aioe Sas I supe nt Fiype of Fund Tana dom IE tent tw su ET ters Senvammat EJ Fouts DD sees satya st Yee Sent am vere ED Mdvex ROL Specal Report Name Dl veartas ED Fat TD seca Account information Financ aston Flame Financ Tsun Fall No BB [e Arcount Cove [Porno [= Account Code Week Re = te CERTIFICATION 1 cemtify tha the Commitee or Fund isin compliance with ll applicable provisions of Article 22A, 228 & 22D.22M of Chapter 163 ofthe NC General Sis so tat no ons at commingled wit) robe ear andl fons. rte ceri hat ths pated ee saatace aw SI'S nfo Panic Name of TD Se rorsars of Apporned Teme [FOR OFFICE USE ONT] sive Emy Delivery Method Date Received: Employee: eee Date Postasked Employee Fest St Date Scanned: Employee: _ 1 Execironically Filed Date Data Eneres Employee: ___©) Signer has not received ee ad ation, of account information. rement of Organization (CRO-2100A-E) to make committee changes, CSc ost or ecoDetailed Summary vine Use this form to summarize all disclosure reporting forms and to total monetary information Champ Clavis et eS Taal Start of Election Cycle: January 1, Zoo‘ Reporting Period _| Election Cycle @ Cash on Hand ats S 1492-1 / RECEIPTS 5) Aggregated Contributions from Individuals crore [Ss b¥0— [8 [5io- duals cronols 4100 — |See4 22 7) Contributions from Political Party Committees «erv-22n S$ Qip — |S 6) Contributions from In de = 8) Contributions trom Other Political Committees exon | 3 Goca — [8 Joe s 9) Loan Proceeds ccroaso)| § 10) Refunds/Reimby s 11) Other Receipt Sources sements to the Committee (cRo-1240) 11a) Interest on Bank Accounts (cR0-1250) 1b) Contributions trom Not-For-Profit Organizations. (CR0-1250 He) Outside Sourees of Income (cR0-1250) 114) Legal Expense Fund - Other Sources (cno-1270) 11¢) Exempt Purchase Price Sales (cro-1265) 12) TOTAL RECEIPTS (Ai ins 5.6 7,8 900.1108 edna He] 13) Disbursements 13a) Operating Expenditures (cRo-1210) 13b) Contributions to CandidatesPolitical Committees (CR0.1310) 13) Coot ted Party Expenditures (ero. 14) Aggregated Non-Media Expenditures (cro-1315) 15) Loan Repayments (cR0-1320) 16) Refunds/Reimbursements from the Committee (eRo-1320) 17) In-Kind Contributions (cro-ts10) fis) TOTAL EXPENDITURES (Add ines 130,150, 5e, 4,15, [and 1 ft9) Cash on Hand at Bd (aati and 12 ogee tan wa cxo-1330) (cx0-1430) Spicer Oates (cxo-1610) 123) Debts and Obligations owed to the Committee (cR0-1620) 4) Account Transfers Within the Committee «cxo-1720) 15) Administrative Support (cRo.1710 6) Forgiven Loans (cRo-144 27) 48-Hour Notice Reports Sum (cR0-2220) £28) Contributions to be Refunded CRO-TTOO NO ne bono eae TapaAmendment Aggregated Contributions from Individuals me | \_ Dye Optional form used to report NC Contributions From Individuals of $50 or less Commitee Ful Name (and Fund Wapplcable) Ia ng Class fee Ciby Council Se a ara RE | Gui Checle cu Chrcle web ON (eV Gece Check Check Cloke Check Credet Coed Cocke Cod Chick Click 4. Total only this Page 5. Total of ALL CRO-1205 Pages (Thieme mus be om line $ of Dele Summary age CRO-1100) CRO-T205 TNC Sine Bondo Ease Apna