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Amendment <br />Other Receipt Sources Pg of ❑ Yes �I No <br />Use this form to report income not repotted on another form. i.e. interest income, not for profit contributions etc. <br />1. Committee FuH Name (and Fund if applicable) <br />2. ID Number <br />/�1 <br />0wnm:�f'� fa Elec- �' glr.r.. F*e&s C I d?k or &L9 <br />3. Type of Receipt source lease use se crate CRO-1250 arms for each CWe of Receipt Source. <br />Co Interest ❑ Contributious from Nat -for -Profit Organizations ❑ Outside Sources of Income <br />4. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />h. Not -far -Profit Federal ID # <br />d. Comments <br />,6 0 / 0 1 o- T'L D-Y- r r 1,U <br />Gfi© fir �/ IVY C' a280 7 <br />c. Outside Source Explanation <br />e_ Election Sum to Date <br />f. Account Code <br />g. Form of Payment <br />h. In-IGnd Description <br />i. Date (mmiddlyyyy) <br />j. Amount <br />I <br />�Y <br />-Dytq <br />- Nresl- t, C?�,c�fi 14i 4,y <br />Znf"eltas ,, Lh er-K ��4 <br />R <br />o'71i$ <br />r 07 <br />`'8/iV <br />4. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Not -for -Profit Federal ID # <br />d. Comments <br />t+,PLO�`�1rs eye l t��lt�c�rz <br />-it) <br />cpr,. (; Cyr.[r h{f C 1� 80ai I <br />7o4 - 993 — 344 <br />c. Outside Source Explanation <br />e. Election Sum to Date <br />f. Account Code <br />g. Form of Payment <br />h. In-IGnd Description <br />i. Date (mm/dd/yyyy) <br />j. Amount <br />4. Contributor Information ❑ Add ❑ Remove <br />a- Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Nut -for -Profit Federal lD # <br />d. Comments <br />f L f"E Em PLO`('c it .5 a rr '� �" Lt-n : o n <br />O � �� f ,� L� <br />Co)cny] , N � � <br />70 4 ' ,799 ._ 34 -4 4 <br />c. Outside Source Eaplauati©n <br />e. Election Sum to Date <br />$ 4, 7, � 1 <br />f. Account Code <br />g. Form of Payment <br />h. In-IGnd Description <br />i. Date (mmlddlyyyy) <br />j. Amount <br />+<-L'1,r.-r <br />Q,2 - <br />$ J <br />5. Total only this Page <br />6. Total of ALL CRO-1250 Pages <br />(This line goes in lure Ila of Detailed Summary Page CRO-II00 iflntemst) <br />(This litre goes in line llb of Detailed Summary Page CRO-1100 if Not for -Profit Cantribudon) <br />(This line goes in fine Ile of Detailed Summary Page CRO-1100 if Outside Sources of Income) <br />$ � <br />CRO-1250 NC State Board of Elections December 2007 <br />