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Contributions from Individuals <br />Use this form to report individual conu*uh= over $50 or conuiludoas tnder $50 if farm CRO 1205 is <br />Aauegdauat <br />❑ YCx ❑ Na <br />not used <br />1. Comndttm Full and Fund' . <br />d N ..btr I ID Number. . <br />cC1'iM i"lTe-'-- (i D Lie-C+ n <br />3. Contributor WbrmatWn <br />❑ Add ❑ Rerwve <br />a. Pali Name, MaNK Addnxs & Phaae <br />b. Job Tifie/Prahseim d Coat�ts <br />C-CW& d . statr, & zip) <br />}rc=.fi r�A, <br />C-EmWimoe=P&mdSwd&FW <br />Io14,!;L0 H[k'r+-worA S�- <br />L'S1► � I c�.nd , N C � � � �n <br />�r� i Cli [,f � c�,sr� n e. ®lC1i0m.141a to NO <br />-- <br />f Prior X. Axoomst Code h. Fw= of Payment <br />i. In-10nd bmwipfim ;. Dale {maalddly"y) <br />lL Aunt <br />❑ � mun� ��r <br />rs� . ,� 1�� �" <br />s 10o t�� <br />❑ <br />$ <br />❑ <br />a <br />l ContillWtor Information <br />El Add ..:: ❑ .... Ye <br />a. Fall Name, Mailieg Addrew & Phome <br />h. Job TWkANvkqWoa d. GIs <br />OWN& ah', stntr. & zip) <br />`' EwOayWt N,se Fidel <br />C'.O oc O,<--I lK C- a5OA-1 <br />e. Beenon to Dale <br />Jo4--743-7v,78 <br />s <br />�� <br />f Prior g Aemmtt Cade L Form of Past <br />i. L"W Deseripdm . ;. Dale [mmMd"yy) <br />iL An t <br />S <br />Contributor Luorn>s3ti m . <br />❑ . Add ❑ .. Remove <br />a. Full Name, ibiag Addmu & Piow <br />by Jol► � a. r,a� <br />[i■ mk city" Sxlr, & �) <br />, <br />[, <br />e. KOPLoyaws �i=mdSperasc Field <br />� MY i.5 k LOaAs <br />COhwYd, NC `�25 <br />Can ttC.Eked=sm.imDmIe <br />- (aqq. L .j <br />L Prior g. Aammat Cade is Farr arrayment <br />i. Ia- mw Detcripaoa ;.Dale (rM'd1Yy97) <br />g. A#toltttt <br />❑ 2 <br />��1�32S <br />S �� 0 <br />❑ <br />S <br />❑ <br />S <br />4. Total only: dins Page <br />5. Total of M L ECRU-IZ O Pages <br />[ S <br />CRO-1210 <br />NC State loud of Elccfam <br />April xoo7 <br />