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Amendment <br />Contributions from Individuals > of ❑ Yes ❑ No <br />Use this form to report individual contributions over $ 5 0 or contributions under $50 if form CRD 1205 is not used <br />1. Committee Full Name and Fund if applicable) <br />2. ID Number <br />�dm.rrI� � zr- zt�-e P4 �: ��- <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Full Name, Mailing Address & Phone <br />(include city, state, & rip) <br />b. Job TitlelProfession <br />d. Comments <br />r�E-f N cl <br />I) 0: e 11e' M <br />f <br />L.I C <br />177-1 RjeA ANC <br />c Employers 's lVamelSperiTir Fielde,40- <br />/ <br />C <br />e. Election Sum to Date <br />f. Prior <br />g. Account Code <br />h. Form of Payment <br />L In -Kind Description <br />J. Date!!(mmlddlyM) <br />k. Amount <br />❑ <br />6�7 �v <br />$ �2 .flo <br />❑ <br />$ <br />❑ <br />$ <br />3. Contributor Information ❑ Add ❑ Remove <br />a. Fail Name, Mailing Address & Phone <br />(include city, state, & sip) <br />b. Job Title/Profession <br />d. Comments <br />�"w ev Ad r Af 2- � <br />c. Employer's Name/Specific Field <br />e. Election Sum to Date <br />$ <br />L Prior <br />* Account Code <br />h. Form of Payment <br />L In -Kind Descri Lion <br />j. Date(mmlddlyyyy) <br />k. Amount <br />El <br />fit, <br />��L5+711d� <br />�I 1� <br />$3�� <br />❑ <br />., <br />3. Contributor <br />Information ❑ Add ❑ Remove <br />a. Find Name, Mailing Address & Phone <br />(include city, state, & sip) <br />b. Job TitlefProfession <br />d. Comments <br />c. Employer's Name/Specific Field <br />e. Election Sum to Date <br />f. Prior <br />g; Account Code <br />h. Form of Pavment <br />L In -Kind O"Cription <br />f. Date (mmlddAM) <br />lc Amount <br />❑ <br />$ <br />❑ <br />$ <br />❑ <br />$ <br />4. Total only this Page $ $9 <br />5. Total of ALL CRO-1210 Pages $ -1 <br />(This line muss be online 6 o f D&alred Summary Page Cftl7-HOO) , q'2'4. <br />CI[U-I210 NC State Board oFFIectkc its April 2007 <br />