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C'ontilbutions front Individuals <br />Amendment <br />pg 14 of 14 ® yes NO <br />Use this form to reuort individual contributions over S50 or contributions under S50 if form CRO 1205 is not used <br />L Cmandtlee FWU Name (sad Fund a _ ,;ek <br />COMMI'1-1'EE f0 ELECT KRISTEL SWAYZE <br />3. Conugmtor Information ❑ Add ❑ Remove <br />a. Full Name, 31ailing Address & Phone <br />b. Jab Titie:'i°tnfeasion <br />............................................. --- -- <br />d. Comments <br />-------------------- <br />(inrinde city, state, & zip) <br />..................................................................._..........-. m-..........-------------- <br />RN <br />TIFFANY YELTON <br />c. f mployer's -Name.+Specific Field <br />...... _.. ............................................................ . <br />822 WA V ERLY COURT <br />CONCORD, NC 28025 <br />ATRIi1M HEALTH <br />e. Election Sam to Date <br />............. --- <br />100.00 <br />E Prior <br />& Account Code <br />h. Form of Payment <br />L In -Kind Description <br />---------------...----------- . <br />j. Date (mmldd+))7y) <br />-.-.-...............------..........................m-- <br />k. Amount <br />--------- --------.-..-..-......--...................... <br />- --- ----------- <br />❑ <br />----------------------- --- -- --- ----- <br />123456 <br />-----------------..-.-.......-......................................................-----•-------- <br />Credit Card <br />01 / 18/2026 <br />S 100.00 <br />❑ <br />5 <br />❑ <br />S <br />3. Coats lattor tnfarms}tion ❑ add ❑ Remove <br />a. Full -Name, 34siling Address & Phone <br />b. Job Title-Panfeasioa <br />................................................................................... <br />d. Comments <br />- ._.............................. ....................... <br />(include city, state,,& zip) <br />......................_......._............. ._.. <br />OFFICE MANAGER <br />GINGER 2SAMBEKY <br />c. Empioger'sNamefSpecific Field <br />....._.......m_------------------------------------ --------------------- <br />10085 ENCLAVE CIRCLE <br />CONCORD, NC 28027 <br />DENTAL OFFICE. <br />e. Election Sum to Date <br />.........................................................._. <br />S 250.00 <br />E Prior <br />g. Account Code <br />h. Form of Fa}ment <br />L In -Kind Description <br />-------- <br />j. Date (mm;4d13)jy) <br />k. Amount <br />........................................ <br />13 <br />123456 <br />Credit Card <br />02/10/2026 <br />5 250.00 <br />❑ <br />S <br />❑ <br />5 <br />4. Total only this Page g 350.00 <br />5. Total of ATI,CRO-1210 Pages S 12,334.45 <br />(This lime arum be on has 6 of Lieraded Samima rz Pale CRO-11001 <br />CRO-1 210 ':c stzt� scY c: Ltectwm April ZIX <br />