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�1 Other Receipt Sources Amendment <br />Pg of ❑ Yes ❑ No <br />Use this form to report income not reported on another form. i.e. interest income, not for profit contributions etc. <br />1. Committee Full Name- and Fund if applicable) <br />2. ID Number <br />L�Ulnrn`i i� �o I t ��3 C � r €3 h Cou.Yi <br />3. Type of Receipt Source Please use separate CRO-1250 Lorm for each type a Recei t Source <br />v <br />® interest ❑ Contributions from Riot -for -Profit Organiz tiom ❑ Outside Sources of Income <br />4. Contributor Information ❑ Add ❑ Remove <br />a. Full dame, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Not -for -Profit Federal ID N <br />d. Comments <br />6o 4i jovA L�3i1 l�t�3 <br />(20 1 '�t'O;-' kq C j sc) aI <br />c- Outside Source Explanation <br />e. Election Sum to Date <br />f. Account Code <br />g. Form of Payment <br />h. In -Kind Description <br />i. Date (mmlddlyyyy) <br />j. Amount <br />1 <br />TX n + <br />-D t <br />Il��'r�st en CY,e_'_ kI ny <br />T'N� <br />o i 11.E�� <br />$ t?7 <br />4. Contributor <br />Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Not -for -Profit Federal ID 0 <br />d. Comments <br />r , <br />c a 90�q <br />'7 a L-- 78s - 344' f- <br />e. Outside Source Explanation <br />e. Election Sum to Date <br />1 <br />f. Account Code <br />g. Form of Payment <br />Jr. In -Kind Description <br />i. Date (mmldonry) <br />j. Amount <br />L,Vti nc <br />�j .� , zea� <br />$ <br />4. Contributor <br />Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Not -far -Profit Federal ID li <br />d. Comments <br />} <br />�04- 'Ie67 - 344- <br />e.Outside Source Explanation <br />e. Election Sum to Date <br />f. Account Code <br />g. Form of Payment <br />h. In -Kind Description <br />i. Date (mmiddlyyyy) <br />j. Amount <br />5. Total only this Page <br />6. Total of ALL CRO-1250 Pages <br />(Thu linegoes in line !la of Detailed Summary Page CRO-1100 if Interest) $ <br />fTlris linegoes in line 11h of Detailed Summary Page CRO-1100 if Not for -Profit Contribudanj <br />fThis linegoes in line l Ic of Detailed Summary Page CRO-1100 ifOuoide Sources of Income] <br />CRO-1250 NC State Hoard of Elections December 2007 <br />