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Contributions from Individuals <br />Amendment <br />Pg. of ❑ Yes ❑ No <br />Use this form to revort individual contributions over $ 5 0 or contributions under $50 if form CRC 1205 is not used <br />1. Committee Full Name (and Fund if applicable) <br />{ <br />2. ID Number <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address chi Phone <br />(include city, state, & zip) <br />b. Job'I'itlelProfession <br />d. Comments <br />rr <br />bona <br />R <br />43.71 Fr,{ <br />r. Employer's Name/Specific Field <br />e. Election Sum to Date <br />$ Z 3q• `i � <br />F. Prior <br />I g. Account Code <br />h. Form of Payment <br />i. In -Kind Description <br />�., Few <br />j. Date [nm(ddlyyyy) <br />]z �� rz s <br />k. Amount <br />❑- <br />�� ,:: <br />r (r(r <br />❑ <br />�� <br />zrzv <br />$ <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Job TitlelPrefession <br />d. Comments <br />c. Employer's NamelSpecific 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 (mmlddlyyyy) <br />k. Amount <br />❑ <br />_. <br />$ <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information ❑ Add ❑ Remove <br />Fail Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Job Title/Profession <br />d. Comments <br />e. Employer's Name Specific Field <br />e. Election Sum to Date <br />.Prior <br />g. Aeeount Code <br />h. Form of Payment <br />i. In -Kind Description <br />J. Date (mm/ddlyyyy) <br />k. Amount <br />$ <br />❑ <br />❑ <br />$ <br />❑ <br />$ <br />4. Total only this Page <br />$ Z 34 • q 11 <br />5. Total of ALL CRO-1210 Pages <br />(This line must be on line 6 ofDetuiled Summary Page CR0-1100) <br />$ <br />CRO.1210 NC Siate Board of Elation,, April 2007 <br />