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Contributions from Individuals <br />Amendment <br />Pg or ❑ Yes ❑ No <br />Use this form to report individual contributions over $50 or contributions under $50 if form CRO 1205 is not used <br />1. Committee Full Name (and Fund if applicable _ _ _ <br />2. m Number <br />-- - <br />t4ee_ tb e ecf <br />3. Contributor Information ❑ Acid ❑ Remove <br />Full Name, Mailing Address & Phone <br />(include city, staate, & zip) <br />�_ I �JT—f � i � t C_ � 21 <br />L lV <br />b. Job Title/Proression <br />`�' y►� <br />d. Comments <br />c. Employer's Namelspecific Field <br />cAhai-oty <br />�t)��'� <br />ate <br />e. Election m tom <br />$ /y <br />f. Prior <br />g. Account Code <br />h. Farm of Payment li. <br />In -Kind Description <br />j. Date (mtnlddlyyyy) <br />k. Amount <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information ❑ Add ❑ Remove <br />Fell Name, Mailing Address & Phone <br />(include city, state, &xip) <br />b. Job TItle/Profession <br />d. Comments <br />c. Employer's lYamelSpecific Field <br />e. Election sum to Date <br />$ <br />.Prior <br />g. Account Code <br />h. Form of Payment <br />L In -Kind Description <br />j. Date (nuulddlyyyy) <br />k. Amount <br />13 <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information El Add [] Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, &zip) <br />b. Job'IUWPmfession <br />d. Comments <br />c. Employer's Name/Specific Field <br />e. Election sum to Date <br />$ <br />Prior <br />❑ <br />g.AccountCode <br />h.FarmofPayment <br />i. In -Kind Description <br />j. Date (mmlddlyyyy) <br />k. Atnount <br />$ <br />❑ <br />I <br />$ <br />❑ <br />$ <br />4. Total only this Page <br />$ Q;;S. <br />Total of ALL CRO-1210 Pages <br />fine muss be on lure 6 of Detailed Summary Page CRO-1100) <br />$ �0�(This 1 CZ <br />CRO-1210 NC State Board of Elections April 2((]7 <br />