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Other Receipt Sources <br />Amendment <br />Pg of ❑ Yes ❑ No <br />Use this forth to report income not reported on another farm. i.e. interest income, not for profit contributions etc. <br />1. Committee Full Name (and Fund if a able <br />_� —�.- _.- .... --... _.. -- -- <br />a [( For, � <br />2. ID Number <br />3. Yype of Receipt Source Please use separate CRO-1250 Lorms for each type of Rece' t Sortrce. <br />r7FInteres[ Contribuliori-� from Nut -fur -Profit Organizations _ (]uiside Snttr<es of Income <br />4. Contributor Information El Add ❑ Remove <br />a. Full Natru, :flailing Address & Phone <br />(include city, slate, & Kip) <br />1h. Nut-for-ProCtt Federal ID # <br />d. Continents <br />Sr- <br />r`' QAC4 Y <br />I Irri ide Source Explanation <br />e- Election Sum to Date' <br />0,`+' <br />f. Account Code <br />g. Form or Payment <br />h. In -Kind Description <br />i. Date (TnWddlyyyy) <br />'. Amount <br />G6 1 A,1 <br />$ 4. ` <br />4. Contributor information Ej Add Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, slate, & -zip) <br />b. Not-[or-Prort Federal [D # <br />d. Comments <br />c. outside Source Explanation <br />e. Election Sum to Date <br />$ <br />f. Account Code <br />g. Form of Payment <br />h. to -Kind Description <br />t. bate (mmlddlyyyy) <br />J. Amount <br />$ <br />$ <br />4. Contributor <br />information ❑ Add ❑ Rcmove <br />a. Full Name. Mailing Address & Phone <br />(inclutle city, state, & zip) <br />b. Not -for -Profit Federal ID # <br />d. Cummenb5 <br />c. outside Source Explanation <br />E Election Sum to ]late <br />$ <br />r. Account Code <br />g. Form ofPayment <br />It. In -Kind Description <br />i. Date zmmlddlyyyy) <br />'. Amount <br />5 <br />5 <br />5. Total only this Page $ a <br />5. Total of ALL CRO-1250 Pages <br />(This line goes in [fur 11a of Deladed Summary Page CRC1-I100 if Interest) $ <br />(This line goes in line I1b of Detailed Summary Page CRO.1100 if.Vot far -Profit Cunoibudon) t <br />(This line goes in line 11c o 'Detailed Summary Page CRCI.1100 [ Grdsidr Sources a lncorne <br />CRU-1250 NC State Board of Elections December 2007 <br />