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In -Kind Contributions <br />Amendment <br />Pg of ❑ Yes ❑ No <br />Use this form to report non -monetary contributions, donations, goods or services provided to the committee or fund. <br />Ilse CRO-121 5 if in -Kind C_ontrihutinns were or will he refitnded within 7 rlavc. <br />1. Committee Full Name (and �if applicable) 2. ID Number <br />�Fund <br />e�o►P47' Pra <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing address & Phone <br />(include city, state, & zip) <br />Tfjl / J7 jjLO� <br />!• '� C L Fa G l=x �YJ Ai Q- S <br />co Na � 0 v7 <br />b. Type of Contribnlilr <br />❑, Individual <br />El Candidate <br />❑ Party <br />❑❑ PAC <br />Referendum <br />❑ Other Receipt Source <br />c. Comments <br />d. Election Sum to Date <br />$� <br />e. llrscription <br />f. Date lmnVddlyvyy) <br />g. Fair MarketAmount <br />l <br />3. Cunt ribulor Information ❑ Add ❑ Remove <br />a. lull 'Nanve. Rlailing address & Phone <br />(include cit), state, & zip) <br />b. Ty pe of Contributor <br />❑ Individual <br />❑ Candidate <br />c. Comments <br />❑ Party <br />❑ PAC <br />Referendum <br />❑ Other Receipt Source <br />d. Election Swn to Date <br />$ <br />Rescription <br />f. Dale (mm/ddlyyyy) <br />g. Fair Markel Amount <br />$ <br />3. Contributor Information E3 Add E3 Remove <br />• . Full Naive. Mailing Address & Phone <br />(include city, state, & zip) <br />b. Type of Contributor <br />Individual <br />❑ Candidate <br />c. Comments <br />❑ Ply <br />❑ PAC <br />❑ Referendum <br />❑ Other Receipt Source <br />d. Election Sum to Date <br />$ <br />e. Description <br />f. Date (nuWdd/yyyy) <br />g. Fair Market Amount <br />4. Total only this Page <br />$ 'j 9. <br />5. Total of ALL CRQ-1510 Pages <br />(This lino mn.0 he on lame 17 of Derailed Summary Page CRU-1l00➢ <br />� 13 V <br />7 <br />CRO-1510 NC State Board of Elections December2007 <br />