HomeMy WebLinkAboutPC2018-02 - Mike Scharnow for Town Council Statement of OrganizationD Initial Application
•Amended Application
Date:
COMMITTEE TYPE (choose one)
Committee Name (required)
(first or last name &office)
Candidate Information:Candidate's Name (required):/KjCR^tel ~^>C-\A.O^Y~j\0 (^
Candidate's mailing address (required):(L?2oC?/*<^OTn^h^MSl^(jV'l<A
Candidate's email address (required):/tyffee SCMp.f'hot^@ COX-nej~
Candidate's phone number (required):^JoU 3ZJl£>""<£'^fy i
Candidate's website (if any):
Office Sought (choose one):•Governor •Secretary of State •Attorney General D State Treasurer
•Superintendent of Public Instruction •State Mine Inspector •Corporation Commissioner
•State Senate •State House of Representatives • District (required):
•County Office:• District (if applicable):
STATE OF ARIZONA
COMMITTEE STATEMENT
OF ORGANIZATION
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Vbity/Town Office:JQidA.
Election Cycle for Office Sought (year the election will take place)(required):
• District (if applicable):
PartyAffiliation:•Democrat • Green • Libertarian S Republican • Other:
(required for partisan offices)
•Political Action Committee (PAC)
Committee Name (required):
(if sponsored,must include
sponsor's name)
Political Function (optional):•Contributions •Candidate-Related Independent Expenditures
(select any that apply)• Ballot Measure Expenditures •Recall Expenditures
Sponsorship Information:
(if applicable)
Sponsor's name or nickname (required):
Sponsor's mailing address (required):_
Sponsor's email address (required):
Sponsor's phone number (if any):
Sponsor's website (if any):
COMMITTEE ID NUMBER
(office use only)
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Special Status
(if applicable)
•Separate Segregated Fund of a Corporation,LLC,Partnership,or Union
•Standing Committee (must also complete separate standing committee registration)
•Mega PAC (must provide proof of Mega PAC status to filing officer)(amended applications only)
D Political Party
Committee Name (required):
(must include party affiliation)
Jurisdiction:
Special Status
(if applicable)
•State Party (must include proof of qualification pursuant to A.R.S.§ 16-801 or §16-804)
•County Party (must include proof of qualification pursuant to A.R.S.§16-802 or §16-804)
•Legislative District Party (must include proof of organization pursuant to A.R.S.§16-823)
• City or Town Party (must include proof of qualification pursuant to A.R.S.§16-802 or §16-804)
•Standing Committee (must also complete separate standing committee registration)
Arizona Secretary of State Revision 11/5/16
❑ Initial Application
❑ Amended Application
Date:
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Contact Information:
H 5 STATE OF ARIZONA COMMITTEE ID NUMBER
� �� ' COMMITTEE STATEMENT (officeuseon�y)
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d �� �� � OF ORGANIZATION
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Committee's mailing address (required): G��i��o /v- �� l'IP�/�S"` ��l 1¢Z �S�'�8
Committee's email address (required): f�'((!� ��a��'f.�L� � COX. Gl �!
Committee's phone number (if any):
Committee's website (if any):
Chairperson's Information: Chairperson's name (required):
Treasurer's Information:
Bank or Financial Instifution:
Chairperson's physical address (required):
Chairperson's mailing address (if different)
Chairperson's email address (required):
Chairperson's phone number (required):
Chairperson's employer (required):
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Chairperson's occupation (required): ��AG(C�'c,lC J�i/i jal�'
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Treasurer's name (required): ��`i� Y� �—�E�E -`.� ft� �i� Y f'i� a✓
Treasurer's physical address (required): /.��G _� C% ��, ��UL2 ��C" �"1(l l�.
Treasurer's mailing address (if different):
Treasurer's email address (required): ; 4�.+c�v`cc� --S f,�c�o�¢��j �4�� �„� y��'�y,�, ( �,(�;�
Treasurer's phone number (required): � � % — � .�L�� "' �� �J �
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Treasurer's employer (required): !/t.'1 t U�� v� � f'"I 1'l.Ct ('l G l e�_.
Treasurer's occupation (required): �1�, k"vr «:� ���U=.5�`�
Bank name (required): L�IM_K of Tf��(�
(do not list acct numbers) Additional bank name (ifapplicable):
DECLARATION AND SIGNATURES:
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Additional bank name (if applicable):
I declare under penalty of perjury that the foregoing information is true and correct. I further declare that I: (1) consent to serve as
chairperson or treasurer of the committee named herein, if applicable; (2) designate the above-named committee as my official candidate
committee and authorize it to receive/make contributions/expenditures on my behalf, if applicable; (3) have read the Secretary of State's
campaign finance and reporting guide; (4) agree to comply with Arizona election law, including campaign finance laws codified at A.R.S.
§§ 16-901 to 16-938; and (5) agree to accept all notifications and legal service of process for campaign finance purposes via the email
address(es) provided herein.
Chair erson's si nature: .( �� �� _-1 Date: � Z� ��J
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Treasurer's signature: / ...r� ..�,---� ' --�' � Date: �
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Candidate's si nat re if a licable : ���' ,� �/�� ��
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Arizona Secretary of State Revision 11 /5/16