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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 $50 if form CR❑ 1205 is not used <br />1. Committee Full blame (and Fund if a licable) <br />2.11D Number <br />C•'�.� �'� iM i' � � - .e � e t 4- �i�I r 3i' � � �ir _Sc � t:� I �C7�� <br />3. Contributor Information ❑ Add ❑ Remove <br />Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />h. ,fol ,HHUT!rofession <br />d. Comments <br />VC <br />c_ Employer's Na Namel5pecific Field <br />e, Election Sum to Dxtr <br />clV f, <br />. Prior <br />g. Account Code <br />h. Form of Payment <br />i. In -Kind Description <br />S. Date (mmlddfyyyy) <br />e <br />h. Amoupnft <br />13 <br />/ <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information ❑ Acid ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />[include city, state, & rap] <br />b, Job Title/Profession <br />d. Comments <br />c. Employer's Name/Specine Field <br />e. F;lUctian Sum to Date <br />f. Prior <br />g. Account Code <br />h. Form of Payment <br />i. In -Kind Description <br />J. Date (mmiddlyyyy) <br />k. Amount <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information ❑ Add ❑ Remove <br />Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. JobTitle/Profession <br />d. Comments <br />— <br />--- <br />c. Employer's Name/Specific Field <br />e. Election Sum to Date <br />.Prior <br />g. Account Cade <br />h. Form of Payment <br />i. In -Kind Description <br />j. Date (nunlddlyyyy) <br />lc Amount <br />❑ <br />$ <br />❑ <br />$ <br />❑ <br />$ <br />4. Total only this Page $ ; <br />5. Total of ALL CRO-1210 Pages <br />$ <br />{This fine must he opt fine d ofDerai&d Summary Page CRQ-1100j V <br />CKU-1d1 0 NC State Board of Elections April 2007 <br />