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Contributions from Individuals <br />Amendment <br />Pg of ❑ Yes ❑ No <br />Use this form to report individual contributions over $50 or contributions under S50 if Form CRQ 1205 is not used <br />1. Committee Full Name (and Fund if applicable) <br />C�� sw y , Z� �'� �c� i✓ c 'f` �� II �`` r <br />2. ID Dumber <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, State, & zip) <br />w� 1h ,.-, A" 6 L- - <br />�� N,. y,� n0 �+� �► i� �3 <br />b. Job'I-it Ielf'rof'essinn <br />5 -�«- <br />d. Comments <br />c. Ftnployer's NawelSpccific Field <br />•�L rr�IYJ 7't <br />la �' P <br />e. Election Sum to Date -- <br />f. Prior <br />g. Account Cnde <br />h. Form of Payment <br />i. In -Kind llescriptinn <br />j. Date {tnmlddlyyyyj <br />k. Amount <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />[include city, state, & zip) <br />h. ,lobTitle/Profession <br />d. Comments <br />c. Employer's Nante/Specific Field <br />e. F,leetlon Sum to Date <br />$ <br />.Prior <br />❑ <br />g. Account Code <br />h. Forms of Payment <br />i. In -Kind Description <br />j. Date fmntlddlyyyyl <br />k. Amount <br />S' <br />3. Contributor Information ❑ Add ❑ Remove <br />Full Name. Mailing Address & Phone <br />linclude city, state, & zip) <br />b. Job Title/Profession <br />d. Comments <br />c. Employer's Name/Specific Field <br />e. Election Sum to Date <br />.Prior <br />❑ <br />,. Account (:ode <br />It. Form of Paiymenl <br />i. In -Kind Description <br />j. Date (mntrddfyyyy) <br />k. Amount <br />$ <br />❑ <br />$ <br />El <br />4. Total only this Page <br />$ ;Ls�� v-us <br />5. Total of ALL CRO-1210 Pages <br />{Tills line must he an fine b of Delailed Sonintarr Page CRO-I100) <br />$ <br />CRO-I2I0 NC State Hoard of Elections April 2007 <br />