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Other Receipt Sources Pg 4 of J-Amendment <br />]Yvs No <br />Use this form to rep o rt inco me n o t rep o rted on an o th er form.i.e.interest inco me,no t for p rofit co n tnb u tion s etc. <br />1 .Commi ttee Full N a m e (a nd F und if a pplica bl e)2.ID Number <br />LC'on:tte E Ele+bacc>Ce or a«r <br />3 .Type o f Rec ei pt So urce [Please use separate RQ-125@ forms_for ea ch type ofReceip t Source.} <br />IX]Inter est LI Contributions from Not-for -Profit Organizations LI Outside Sour ces of Income <br />4 .Contri buto r Inf o rma ti o n □Add □Remo v e <br />a.Full Name,Mailing Address &Phone b.Not-for-Profit Federal ID #d.Comments <br />(include city,state,&zip) <br />S'fake mas Cedt n!en <br />o Ra {av4 Dve Mo c.Outside Source Explanation <br />Cenco4,Nd 2so29 e.Election Sum to Date <br />)4-17 344/$2 7 .3 6 <br />f.Account Code g.Form of Payment h.In-Kind Description i.Date (mm/dd/yyyy)j .Amount <br />I Des t Llees t dec ln9 /ah2>$.o7 <br />I <br />I D«s t ftevest on Cke n q //a/023 $.0 <br />4 .Contri buto r Info rm a ti on □Add []'Remo v e <br />a.Full Name,Mailing Address &Phone b.Not-for-Profit Federal ID #d.Comments <br />(include city,state,&zip) <br />S4ate En-oye=>Cell ln}on <br />o Rab4ovd D t>c.Outside Source Explanation <br />C onc oid,3 so 2 '7 e.Election Sum to Date <br />74-1 89 -3 44 $21. <br />f.Account Code g.Form of Payment h.In-Kind Description i.Date (mm/dd/yyyy)j .Amount <br />I Da s Le e s+onCheck'n q o3//Ao3 $.05 <br />t Dag+Theres on Checl inq w/a/,ez a $,o <br />4 .Contri buto r Info rma ti o n □Add □R em o v e <br />a.Full Name,Mailing Address &Phone b.Not-for-Profit Federal ID #d.Comments <br />(include city,state,&zip) <br />Sa le E no =Cor n /o noRa±9 e l D N u)c.Outside Source Explanation <br />cd,e a8ox7 e.Election Sum to Date <br />)4 -1 93-3f44 $2151 <br />f.Account Code g.Form of Payment h.In-Kind Description i.Date (mm/dd/yyyy)j .Amount <br />I De+T kevesl o Checkinq o5lo/a3 $.05 <br />I <br />1 De«gr D Ie et o Ch eek n 6 h 3/0 13 $·0 <br />5 .T o tal o nly this P age $ <br />6 .T o tal o f AL L CRO-1 2 50 P ages <br />(This line goes in line I la of Detailed Summary Page CRO-I10o if Interest)$35,. <br />(This line goes in line l1b of Detailed Summary Page CRO -I100 if Not-for-Profit Contribution) <br />(This line goes in line I l c of Detailed Summary Page CRO -I100 if Outside So urces of Income) <br />CR 0-125 0 NC State Board of Elections December 2007