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Other Receipt Sources <br />Amendment <br />Pg of 1 13 Yes 10 No <br />Use this form to report income not reported on another form. i.e. interest income. not for nrofit contrihutions etc <br />1.��C��ommittee FuH Name (and Fund if ap-Ocabie) <br />2. ID NUM- ber <br />C; Mn)`-f t- e4v �'T.B�T�s �Rk op C6 r -- <br />I Type of Receipt Source Please uses a CRO-1250 forms or each e a Receipt Source. <br />Interest Contributions from Nat -for -Profit Organizations Outside Sources of Income <br />4. Contributor Information ❑ Add Remove <br />Fill Name, Mailing Address & Phone <br />(iadude city, state, & zip) <br />S I R7 �MFIflYc"7ES Lea IT �IrlPorl <br />Go 419IF6RD PCtwc Na) <br />90PICoOPD1 Ijib, 46b.27 <br />7c�-7g:?--3444 <br />b. Not -far -Profs Federal ID # <br />d. Comments <br />- - - <br />e. Outside Som-ceExplsnation <br />e- Election Sum to Date <br />$ � �)� <br />. Account Code <br />g. Form of ftyment <br />h. In -Kind description <br />i. Date (nxmlddlyyyy) <br />�� o� io <br />". Amount <br />$ 80 <br />t <br />D;m F T <br />T,E�Fsi o W uei <br />DRAFTER�sT <br />�N Crs'� Iti ' <br />a� i �:loa 4; <br />$ eL <br />4. Contributor <br />Information ❑ Add El Remove <br />Full Name, Mailing Address & Phone <br />(include city, state, & sip) <br />b. Not -for -Profit Federal ID # <br />d. Comments <br />- <br />c. Outside Source Explanation <br />e. Election Sum to Date <br />Account Code <br />g. Fonn of Payment <br />it.1th-Kind Description <br />L Date (umulddlyyyy) <br />'. Amowd <br />4. Contributor <br />Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(nclude city, state, & sip) <br />h. Nat -for -Profit Federal ID # <br />d. Comments <br />m <br />c. outside Source Explanation <br />e. FAection Sum to Date <br />. Account Code <br />g. Form of Payment <br />h. In -Kind Description <br />L Date (mnWddlyyyy) <br />'. Amount <br />5. Total only this Page $ f ►ij,;� <br />S. Total of ALL CRO-1250 Pages <br />(This line goes in line Ila of Detailed Summary Page CRO-1100 if Interest) $ <br />(This line goal in line 11h of Detailed Summary Page CR04I00 if Not far -Profit Coarrihrttion) <br />(This linegoes is line Ile o Derailed Summary Page CRO-1100 if Outside Sources a Income <br />r.r[u-izau NC Mate Board of )elections December 2007 <br />