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Contributions from Individuals i of Amendment <br />No <br />Use this form to report individual contributions over $50 or contributions under $50 if form CRO 12u:) is not used <br />1./rCommittee Full Name and Fund if applicable) <br />2. ID Number <br />-Uthrrl i �� �O <br />C�gp' 0'- �xr <br />3. Contributor Information <br />❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />b. Job Title/Profession <br />& Comments <br />(include city, state, & zip) <br />Tf} jL W i 4L, i FoR?] <br />c. Employer's NamelSpecilic Field <br />4(o4o -D®vO- k; LU 1.0, ,, <br />a ! S J e <br />k�na.� k • er►� i <br />S �,t <br />e. Election Sum to Date <br />'7C4-7al-03216 <br />$ 3,500 <br />f. Prior g. Account Code IL Form of Payment <br />i. In -Kind Description j. Date (mmlddlyyyy) IL Amount <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information <br />❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />h. Job Title/Profession <br />d_ Comments <br />(include city, state, & rip) <br />ej <br />�y, <br />Vl �u'(�'�- <br />-` <br />c. Employer's Name/Specific Field <br />1(.06 <br />C2 Q 0tatyA } w [ <br />T �[1 <br />e. Election Sum to Date <br />104-V -13Q <br />s _q,o e <br />f. Prior g. Account Code h. Form of Payment <br />i. In -kind Description j. Date (mmlddlyyyy) k. Amount <br />❑ <br />G - <br />0'7 oq <br />D <br />AOx5 $ 5, Om`' <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information <br />❑ Add ❑ Remove <br />a_ Full Name, Mailing Address & Phone <br />b. Job TitielProfession <br />d. Comments <br />(include city, state, & up) <br />1 _ L ' ftch W - 4a `1 <br />e. Employer's NamelSpecifte Field <br />[ i ❑ i -DogwooA �o-Y 1L <br />���7 <br />i rL <br />e. Election Sam to Date <br />i Prior g. Aeconnt Code b. Form of Payment <br />i. In-iGod Description j. Date mm/d [ dlyyyy) k. Amount <br />❑ 1 C il� �K <br />ny 10 I <br />at � <br />❑ <br />$ <br />❑ <br />$ <br />4. Total only this Page <br />$ /3L 6100 <br />5. Total of ALL CRO-1210 Pages <br />[this line nurse be on lexe 6 ofDMdLedSummary Page CRO-7100) <br />. f <br />$ a�-1 p�%47 <br />CRO-1210 <br />NC State Board of Elections <br />April 2007 <br />