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Contributions from Individuals <br />Amendment <br />Pg of ❑ Yes ❑ No <br />Use this form to revort individual contributions over $50 or contributions under $50 if form CRO 1205 is not u-wd <br />1. Committee Full Name (and Fund if applicable) ___ <br />C e, �, _ , `6 t- - �l�c�,4:rZ" <-- <br />2. 1D Number. <br />. Contributor Information ❑ Add ❑ Remove <br />Full Name, Mailing Address & Phone <br />(laclude city, state, & zip) <br />b. Job Ti de/Pro ressio n <br />d. Comments <br />J �7 <br />c. Employers Name/Specific Field <br />)e� G9 ,C. �7TG��G <br />e. Election Sum to Date <br />.Prior <br />ig.AccotmtCode <br />h. Farm of Payment <br />i. In -Kind Description <br />j. Date (mreJddlyyyy) <br />k. Amount <br />❑ <br />c <br />�r� <br />Fl�rl� <br />d- tl <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />h. Job ltielProfrssivn <br />d. Comments <br />c. Employer's Name/Specific Field <br />e. Election Sum to Date <br />$ <br />f. Prior <br />g. Account Code <br />h. Farm of Payment <br />i. In -Kind Description <br />j. Date (mm/ddlyyyy) <br />k- Amount <br />❑� <br />$ <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Job TitlelProfession <br />d. Comments <br />c. Employer's NamelSpecifle Field <br />e. Election Sum to Date <br />$ <br />. Prior <br />g. Account Code <br />h. Form of Payment <br />1. ]In -Kind Description <br />j. Date (mm /ddlyyyy) <br />k. Amount <br />13 <br />❑ <br />$ <br />❑ <br />$ <br />4. Total only this Page <br />$ <br />5. Total of ALL CRO-1210 Pages <br />(rkis line must be on fine 6 of Detailed Summary Page CRD-IIDO) <br />$ a. - <br />`5 <br />CRO-121 0 NC State Board of Elections April 2007 <br />