(BNCACOD.9I1 ELECTION PROTEST FORM All eon ringing election protest under Par 4 of Article 20 shall complete ad tinely le he folowing Form, Forthe purposes ofthis Ral, “mely” mean within the time required by O.S. 1634-11770), Please note he form ‘shal ot be edt challenge he registration o an individual voter ot repr an inien other than an regulary acting the cucome of an election, ELECTION PROTEST (Use ofthis form is equied by G'S. 1634-11716) “This form must be filed with th county boar of elections within the timefames set out in GS. 163A-11770N4, Please print or type Your answers, Use addtional sheets i need o sneer te below questions fly. Number te pages ofall addtional shets. Pease note that flings willbe a publi record. Pease react all cocenal Frfomation sich as date of bith, Social Security number and drive's license number. Respond to all prompts, Failure to complet this form a required may result inthe dismissal of your protest Acach addtional sheas as necessary, Including all exhibis and supplemental documents. ll atachmeats are deemed Incorporated and covered unre Protest Certain PROTESTOR |. Provide you gett cont afrmatan: L ‘Nim v couny ofResidert: Brownsucrek E27. Eralt Phone wg Miloghatest Leaeet Ch enced TRS = a _ NOTE: You willbe deemed to consent to servic at al of fe shove adresses Coclnding emai, ness you tach an addendum indiesing oer, 2.Aveyou represented by counsel? Yes wo NOTE: If you answered Yes, above, your counsel must complete and yor must aach the Counsel Ceniteation AdSendim, |. Maral ht desert you 1 Candide forthe office of _ —— ‘Pegi voter lige oparipte ne potesed election cones, Nether ofthe above" “Yfyuselet this option you are no eligible fea protes. PROTEST SCOPE 4. List all lectin contests subject to your protest an caleulte the margin of votes spurting the apparent winner om the eunerap as of the dae offing” Vou espose doesnot waive Jour ight to cvtest the val af te ‘uentvote cout If your pots concems al coats onthe balla, you fost lcd the vote margin for ech Proteted Contests) Carrent Vote Margin ‘Example Major of Fownsle Uae Commissiene This protest alleges (selec teat oe)1A defet in the manser by which votes were counted of ress abused sient to cast doubt onthe sppatent results ofthe election, Aviation of election aw, iepuaity, of miscondet sient o eat doubt onthe appeent ress ofthe ‘deton FACTUAL BASIS & LEGAL ARGUMENT 6. Provide al facta allegations in support of your protest. If any fact you allege is ouside the scope of your personal knowledge, you may atach afisvits from haze who have personal knowledge of at fc. All fis ou legen conection wth th prtet must be tre and acarate tote est of your knowledge, and brought ithe Finer elie thatthe fact llged forma good faith bait protest the condat sd resis ofthe election Town 7. ist al individual, if any, you may cl as witneseso subtitled in Prompt 6, there ee mukiple Indias, Surimaize he it of which te ingles personal knowledge fe ‘Be Beedle, 4. ce any ste orcs, adnate rl or eons, and lection poly procedure at pers our li Stoo onder Prompt Cenecs ‘. 1¢o A — RELIEF 8. What fect do you belive tect allege in response o Prompt 6, if proven will av on the electoral outcome fn the prteted conten? Your retponte should seount forthe caren vote margin elated in respons to Prompts {Pele ame of be reese cone) il ng. electoral outcome ofthe protested contest) wl at change. ‘Lam uncertain ether the osteome ofthe cote) wil kang, Other 10, What elie do you seek? ' Carethe vote count ET caucuce aul Ses agamet Belville.ASSISTANCE 1. Listll persons who assed you in preparing the contents of his pots a indicate the nature ofthe assistance proved ‘Noe: For protestors represented by an atone, thls protest the ina ling in a proceeding as defined by WC. State Bar Rules. Soe 27 N.C-A.C. 02 Rae 1.090). 12. Has any candidate, pola party, organization, or person acting on behalf of the same requested that you bing this proest? Bye SNe 13 Have you received any financial or ther benefit or promise of fate fnacialo other benefit exchange for Fling this protest? ayer No AFFECTED PARTIES & SERVICE ‘You must serve copes of ll lings on every person witha diet sake in the outcome of his protest (Affeted Paris). Affected Pare inclde every canidateseking nomination or election inthe protested cenes()lited under Prompt 4 ot only the apparent winner and run-up. Ifa protest concerns the eligibility or ielighiy of paral voters al such votes are Affected Parties and must be Seved.Adatess information fr registered vers [valle tom the county bond of election rung te Voter Lookup at www ncrbe.gov Materials may be served by personal delivery, tranmital trough U.S Mall or commersial caer src tothe ‘Affected Parts mallng adress of rocord of ile with the county board of elections othe Stare Beard, oF by any ther means aflenaivelyauorzed by the AMected Pay Ifyou knot the Affected Party i repesented ban ttorney, service must be made on his or her counsel. Service must occur within one (I) business day of fling Insel with be county board of elecions If Services by tansntal Though the U.S. Mall or camwoeeal earier Service, service wil be complete when te properly eddesed,postge-pald pare is deposed ino the care 20d fusioy ofthe US Mallar commercial euler servis. tis your responsibilty to ensue seve Is mage on all, ‘tected Paces, 14 List all Adit Pats, inchng her sevie addres: Mfected Party he oT PROTESTOR CERTIFICATION 15.8y signing his protest ppiaton, you sin the allowing 1 Athugely™ “TPoweaal/ ill name), swear, ander pay of per, tha the ibeason povided in his trae ne adden owl a av ea and co eloint "have reviewed the statutes and administrative rules goveing election protest, incudg al deadlines protest must rginae with ling athe county board of elton. mus timely serve al Affected Pars. mist prove by vubsanfalevdence citer the existence ofa defect n the manner by which votes were ‘counted or res ablated or the ossurence ofa vislstion of section law, imeglaiy, or misconduct, ‘ther of which were silent to cat doubt onthe apparent sults of th election. [eis crime inetere unlawfully with the conduct and etifieation of a elecion, tis rime to ierfereunlawly with he ability of @ quid individual eve and wo have that vote counted inthe lection. ‘The fs allege in connection with this protest are ve and accurate tthe best of my knowledge, and have a god fat basso proces th condoct and resus ofthe lection, Submitting fraudulently or fey completed declarations isa Clase 1 felony under Chapler 163A of the (General Statutes. This notices provided pursuant. 2013-381, 5.5, sipereatroe: Zaraaly VaanOilpy —— ooe_t1/2/ 219 Thatta man bonged eee Stat of North Caran, Couny of PAN SWiK ‘Swom or affine) and subscribed before me hsihe Tay of NOVErnlaa0_[4 Offical Signatre af Nowy Spe Lots, near Pac Primed Name My comics pier SAS [AL ain led wi Cy Bou fafa 32 ar, ‘Gorillas byte county bows) NOTE: The county board must provide the Sate Board with a complete copy of x file poet within one business day fer is fled ation the county Board stall provide scopy of the election txt with thi copy of the proves. Pease direct any questions 19 your county board of elections or the North Carolina State Board of Elections & thes Enforcement, PO Box 27285, Raleigh, NC 27611-7255,‘COUNSEL OF RECORD ADDENDUM. ‘you answered Yes o Prompt 2 onthe above, your atornay must complete hs frm and ou mus fle wlth your Election rotet Application Atty Must complete al ofthe following: Protester Name Proetor County: ‘tore Name: ‘torey Ema: Attorney Phone: 11am member in good standing withthe North Carling State Bar Stam st licensed to. pase aw in Nort Carlin. but am a member in good sanding. in (State of Dstt of Columb), and do hereby apply to appear pro ec vce and ceil ‘Far Tave owl file al appropriate documents required under G.S. 4-4 Law Fim: ‘ar Number 1 (choose one) cam oa not Subject 10 any order of any court or adminsrave agency asbaring, suspending, ejolaing,resalning, or ‘others restricting me inthe practice of aw. I you are subject oany odes, explain in the space below. | represent the Prtetor whose name is provided above. Ihave read and understand the laws governing lection protets in Noth Carolina General Suruies Chapter 163A and Title 3 of he NC. Adminsraive Code. 1 ear tes th the information| have provided in tis Addendum ste ad acute the best of my knowledge ‘Roey Sate Dae etary Note: Autry GS. 1634-741; 1614-1177 Temporary Adoption Eft April 15, 2002 fag 2004; Readopted Eff September |, 2018