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Amendment <br />Refunds/Reimbursements To the Committee Pg l of 1 ❑ Yes No <br />Use this form to report refunds received by the committee or reimbursements for a previous expenditure. <br />1. Committee Full Name (rand Fund if applicable) <br />2. ID Number <br />( tom ti ',4er� 4 GjecC - B c.4. DRG&s (�Dux+ <br />3. Contributor Information ❑ Add Remove <br />a. Full Name, Mailing Address & Phone <br />(include city. state, & zip) <br />d. Type of Committee <br />g. Comments <br />❑ Candidate ❑ PAC <br />❑ Referendum ❑ Party <br />t E5Td11r� Y c�lll�l erG <br />f 1 <br />6'61W O_Y'rEX1 C . � 5t: r}�Y1�1�� . <br />~+ 7 <br />w4. go3A(65l <br />e. Level Registered (Specify) <br />h. Original Expenditure Date <br />❑ Pederai JE County: <br />0 State ElMuni6pality: <br />09 `/10 a3r <br />i. Original Expenditure Amt <br />$ 1, Si-f . 5'a <br />b. Job TitieTrofession <br />c. Employer's Name/Speeil:c Field <br />%Purpose <br />j. Election Sum to Date <br />awner <br />I6ol lY1i les or,�Ye�►wt~ <br />R �n ' Zfws i f ' <br />$ l l S 1 `� � 5� <br />k. Account Code <br />l_ Form of Payment <br />m. hi -Kind Description a. Date (mmlddlyyyy) <br />o. Amount <br />jQe� <br />�e Clectx,un� z� aa.o�5 <br />$ 1,'0 �� <br />3. Contributor Information ❑ Add Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & rip) <br />d. Type of Committee <br />g. Comments <br />❑ Candidate ❑ PAC <br />❑ Referendum ❑ Patty <br />r- Level Registered (Specify) <br />h. Original Expenditure Date <br />Federal ❑ County. <br />❑ State ❑ Municipality' <br />i. Original Expenditure Amt <br />b. lob TidcAProfcssion <br />c. Employer's Name6pecifie Field <br />f. Purpose <br />j. Election Sum to Date <br />It- Account Code <br />I. Farm of Payment <br />m. In -Kind Description <br />A. Date (mmlddlyyyy) <br />o. Amount <br />3. Contributor Information Lj Add El Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & op) <br />d. Type of Committee <br />g. Comments <br />❑ Candidate ❑ PAC <br />❑ Referendum ❑ Party <br />e. Level Registered (Specify) <br />h. Original Expenditure Date <br />❑ Federal ❑ County: <br />❑ stale ❑ Municipality: <br />i. Original Expenditure Amt <br />b. Job TiHelProfession <br />C. Employer's NamelSpecific Field <br />f. Purpose <br />j. Election Sum to Date <br />k. Account Code <br />urm of Payment <br />m- In -Kind Description. <br />n. Date (mmldd/yM) <br />v. Amount <br />T <br />4. Total only this Page $ <br />5. Total of ALL CRO-1240 Pages $ <br />7iris litre owsr be on line 10 o Derailed Srrmma • Pa a CRO-1100 <br />CCU-1240 NC State Board of Elections December 2007 <br />