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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 $50 if form CRO 1205 is not used <br />1. Committee Full Name (and Fund if applicable) <br />rvt <br />2. ID Number <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, flailing Address & Phone <br />(include city, state, & zip) <br />Cry&_ L�"4 <br />J �'� <br />to �► K w�11 —S <br />9-W.2 <br />� <br />b. job TitlefPrnfession <br />d. Comments <br />c. Employer's NamelSpecific Field <br />S P� r}��c'iS c..I't'�� <br />I <br />e. Election Sum to Dale <br />f- Prior <br />g. Account Code <br />h. Form of Payment <br />i. In -Kind Description <br />j. Date (tnnnlddlyyyy) <br />k. Amount <br />❑ <br />$ <br />❑ <br />5 <br />. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. Job TitlelProfession <br />d. Comments <br />c. Employer's NantelSpecific Field <br />e. Election Sum to Date <br />Prior <br />❑ <br />g. Account Code <br />h. Form of Payment <br />i. In -Kind Description <br />j. Date (mmlddlyyyy) <br />IL Amount <br />S <br />❑ <br />S <br />❑ <br />$ <br />. Contributor Information ❑ Add ❑ Remove <br />Full Name, Mailing Address & Phone <br />(include city, state, & zip) <br />b. job Title/Profcssion <br />d. Conunents <br />c. Employer's Name/Specific Field <br />e. Election Sum to Date <br />. Prior <br />g. Account Code <br />h. Form of Payment <br />i. In -Kind Description <br />Date (mmlddlyyyy) <br />Ic Amount <br />$ <br />13 <br />❑ <br />$ <br />4. Total only this Page <br />5. Total of ALL CRO-1210 Pages <br />(This line must be an line d of Detailed Summary Page CRO-1I00) <br />$ <br />C.'RO-1210 NC State Board of Elections April 2007 <br />