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HomeMy WebLinkAboutMike for OV - Statement of Organization - 1/5/2024® Initial Application STATE OF ARIZONA COMMITTEE ID NUMBER O Amended Application COMMITTEE STATEMENT (office use only) Date: f /S /7 OF ORGANIZATION v L COMMITTEE TYPE (choose one): O Candidate Committee Name (required): _ �i /< ; _ - O V (first or last name & office) Candidate Information: Candidate's Name (required).- / n/ k .✓ Candidate's mailing address (required): % / 2 G Candidate's email address (required): -,/ ����� �95��. c •:y Candidate's phone number (required): S` G `� -7=31- Candidate's website (if any): Office Sought (choose one): ® County Office: ODistrict (if applicable): OCity/Town Office: CIO ODistrict (if applicable): O School Board Office: O District (if applicable): O Special District Board: ©District (if applicable). - Election Cycle for Office Sought (year the election will take place) (required): 2 O 2 Party Affiliation: O Democrat O Green O Libertarian O Republican O Other: (required for partisan offices) E3 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) Special Status (if applicable) O Political Party Committee Name (required): (must include party affiliation) 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): ❑ 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) Jurisdiction: O State Party (must include proof of qualification pursuant to A.R.S. § 16-801 or § 16-804) O County Party (must include proof of qualification pursuant to A.R.S. § 16-802 or § 16-804) O Legislative District Party (must include proof of organization pursuant to A.R.S. § 16-823) O City or Town Party (must include proof of qualification pursuant to A.R.S. § 16-802 or § 16-804) Special Status O Standing Committee (must also complete separate standing committee registration) (if applicable) Arizona Secretary of State Revision 7/29/2021 IN Initial Application STATE OF ARIZONA COMMITTEE ID NUMBER Amended Application COMMITTEE STATEMENT (office use only) Date: i/� �:�,�Y OF ORGANIZATION 01/ 77L a Y -oa COMMITTEE INFORMATION: Contact Information: Committee's mailing address (required): 5/5 Committee's email address (required): /"� �� 6 ✓ �' %` �� c� '' Committee's phone number (if any): -7 C- Committee's website (if any): Chairperson's Information: Chairperson's name (required): Chairperson's physical address (required): i/ 5'2 v .�i "0�, Chairperson's mailing address (if different): Chairperson's email address (required): �f'_7_..1J A�-f.V tS zls�/• c ,� Chairperson's phone number (required): 2 e ` ` —7 c' -� =y Chairperson's employer (required): let Chairperson's occupation (required): �`Ji t %�74 Treasurer's Information: Treasurer's name (required): / Ate 5,te ee-ns Treasurer's physical address (required): 720 W Lv ise/e rare 4►h r� Treasurer's mailing address (if different): Treasurer's email address (required): ��tey C tZ ^& L 1 d) Treasurer's phone number (required): .f 196 71 Z — 1Q S /� Treasurer's employer (required): /T t `f1 re Treasurer's occupation (required): C ! ��r a i� Bank or Financial Institution: Bank name (required):1�a.f�,�,�' (do not list acct numbers) Additional bank name (if applicable): / Additional bank name (if applicable): DECLARATION AND SIGNATURES: 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. / � _ Chairperson's signatun Treasurer's signature: Candidate's signature ( Date: S 2 Date: ( A-1 Date: Arizona Secretary of State Revision 7/29/2021