Farris,Daniel_2025-35-DayDisclosure Report Cover AmYes endment p No
Use this form for general report and committee information, must be signed and submitted along with other detailed forms.
rin not use this fnnn inundate information -
1. Committee Information
. Full Name
c.ID Number
COMMITTEE TO ELECT DANIEL FARRIS
RJM 12
. Melling Address (indude Cay, State sod TJp Code)
& Date FBd
4003 ENGLISH OAKS CT.
WAXHAW, NC 28173
MlR L�Ea,J
a Phone Number
704-519-2444
2. Report Year
3. Period Start Date (mml_ 4. Period End Date (mmldtyyy)
15. Treasurer ftll Name
2025
1 07/19/2025 09/23/2025
DANIEL FARRIS
6. Tym of Committee ((Check One)
Candidate Campaign ❑ Party
❑ PAC ❑ Referendum
❑ Independent Expenditure ❑ Joint Fundraiser
❑ Legal Expense Fund
9. Thypee of Report (check
only one type of re
from one category)
Municipal
Statelemanty
lReferendum
® organizational
❑ Thirty-five day
❑ Pre-primary
® Pre<lection
❑ Pre -runoff
Semi-annual
❑ Mid Year
❑ Year End
❑ Final
❑ Special
0 Organizational
Quarterly
❑ First
❑ Second
❑ Third
❑ Fourth
Semi-annual
❑ Mid Year
❑ Year End
❑ Final
❑ Special
Q Organizational
❑ Pre -referendum
❑ Final
❑ Supplemental Final
❑ Annual
❑ Special
7. Irpe of Fand (if applicable, check one)
❑ Booster Fund
❑ Building Fund
Other.
10. special Report Name
8. Number of Fundraisers this Report
3
11. Account Information
11. Account Information
. Financial Institution Full Name
a. Financial Institution Full Name
rGE
TRUIST
. purpose
c, Account Code
b. Purpose' '"
a Account Code
35 -Day Report
1240
SEP 2 9 h
f RECEIVE_
d. Period Begin BalancePeriod
Begin Balance
$ 'Y"-4+ 15 t
§
CERTIFICATION
I certify that the Committee or Fund is in compliance with all applicable provisions of Article 22A, 22B & 22D -22M of Chapter 163
of the NC General Statutes and that no funds are commingled with prohibited or other non -disclosed funds. t further certify that this
report is complete, true and correct and that I have been trained by the N State B and of Elections.
o
1JaymieAAt 6cp
Printed Name of Signer Signal= of Appointed Treasurer Date
FOR OFFICE USE ONLY ,, ' , , I n
Date Received: Employee: Delivery Method
❑ Normal Mail
Registered Mail
Date Postmarked: Employee:
Hand Delivered
Date Scanned: Employee: Electronically Filed
Date Data Entered: Employee: ❑ Signer training
Please Note: This form cannot be used to amend committee information such as the committee address, treasurer,
assistant treasurer, custodian of books information, or account information.
You must amend the Statement of Organization (CRO -2100A -E) to make committee changes.
CRO -1000 NC State Board of Elections August 2008
Amendment
Detailed Summary ❑ Yes ❑ No
I Ic> thic fnr,n to cummarivn all tlicrincnre rennnino fnrtns and to Intal mnnetary information
1. Committee Full Nam (and a 'cable)
I2. Type of Report
3. ID Number
COMMITTEE TO ELECT DANIEL FARRIS
35 -Day
RJMQ12
Start of Election Cycle: January 1, GDA 5
Total this
Reporting Period
Total
Election Cycle
Cy
4) Cash on Hand at Start
$ 754-.� 151,-JLOI 1 O
$
RECEIPTS
5) Aggregated Contributions from Individuals (CRO -1205)
6) Contributions from Individuals (CRO -1210)
7) Contributions from Political Party Committees (CRO -1220)
8) Contributions from Other Political Committees (CRO -1230)
9) Loan Proceeds (CRO -1410)
10) Refunds/Reimbursements to the Committee (CRO -1240)
11) Other Receipt Sources
lla) Interest on Bank Accounts (CRO -1250)
1lb) Contributions from Not -For -Profit Organizations (CRO -1250)
Ile) Outside Sources of Income (CRO -1250)
lld) Legal Expense Fund - Other Sources (CRO -1270)
Ile) Exempt Purchase Price Sales (CRO -1265)
$ 50.00
$ j+ �!
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
12) TOTAL RECEIPTS (Add lines 5, 6,7,8,9, 10,1 la, I I b, I Ic, I Id and I le)
EXPENDITURES
13) Disbursements
l3a) Operating Expenditures (CRO -1310)
13b) Contributions to Candidates/Political Committees (CRO -1310)
13c) Coordinated Party Expenditures (CRO -1310)
14) Aggregated Non -Media Expenditures (CRO -1315)
15) Loan Repayments (CRO -1420)
16) Refunds/Reimbursements from the Committee (CRO -1320)
7) In -Kind Contributions (CRo-lsl0)
OWL—
$ 1,818.69
$
$
$
$
$
$ 138.63
$
$
$
$
$
$ 349.98
$
18) TOTAL EXPENDITURES (Add lines 13a, 13b, 13c, 14, 15,16 and 17)
$ ()
$
19) Cash on Hand at End (Add lines 4 and 12 together, then subtract line 18
$
$
ADDMONAL INFORMATION
0) Non -Monetary Gifts Given to Other Committees (CRO -1330) $
1) Outstanding Loans (Ind. ones from other campaigns) WRO.1430) $
Debts and Obligations owed by the Committee (CRO -1610) $
;AIVfPAt�,N Ft
23) Debts and Obligations owed to the Committee UNION24) (
Account Transfers Within the Committee (CRO -1720) $
5) Administrative Support SEP (�-7A%� $
Af
6) Forgiven Loans Aar—
7) 48 Hour Notice Reports Sum CRO-zzzo) $
_
$
$
$
8) Contributions to be Refunded (CR0-1215) 1 $
$
CRO -1100 NC State Board of Elections August 2008
Amendment
Aggregated Contributions from Individuals Page _ ar _ ❑ Yes ❑ No
Optional form used to report NC Contributions From Individuals of $50 or less
1. Committee Full Name (and Fund N a cable)
2. ID Number
COMMITTEE TO ELECT DANIEL FARRIS
RJMQ12
3. Contributor information
. Amend
b. Account Code
e. Form of Payment
——
d. In -Mad Description
e. tate (mm/dd/yyyy)
r. Amount
$
Add
❑ Remove
NkMR
STRIPE
Contribution
08/09/2025
50.00
Add
$
❑ Remove
Add
$
❑ Remove
El Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
ET Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
Ej Add
$
❑ Remove
Add
$
❑ Remove
Ej Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
l'
Add
$
❑ Remove
r \ 1
EETTAdd
$
❑ Remove
Add
$
Remove
4. Total only this Page
$ 50.00
5. Total of ALL CRO -1205 Pages
$
50'00
(This fine mast be online 5 of Detailed Summary Page CRO -1100)
CRO -1205 NC State Board of Elections Apnl 2007
Contributions from Individuals
Amendment
Pg ( ofp1 ❑ Yes ❑ No
UIC It 1p IVl In 1. 1UP.L1 HH -11 V LLn1[II 1U11111 UU11UIIN UVC I JJ\, UI 1U11n IUUl1U11N LII IUCI JJU 1, IU, 111 LI Ll„ IN IIUI „
1. Committee Full Name (and Fund it applicable) 2. ID Number
3. Contributor Intormatiun ❑ .
1. Full A,unr, Al:dlin„ -A rldrues & Phonr 1
(include city, slate, & zip)
r—f`f t>k
g3�4q bAl IvVk\`'
° YJ
a. Full Name, flailing Address & Pbone
(include city, state, & zip)
JuSGWI mafClYlili UNIONLOUN
CAMPAIGNFINAN'
�. 1..I �a 13aJn� SEP 29 2025
3':'�Contributor Information I
a. Full Name, Mailing,\ddresN & Phonc
//(iinclude city, state, & zip)
Whf, i+ec iz Oe -J
3ttcb ��vi- ;74M
f. Prior g. Account Code h. Forneof Payment 1. In -Mind
❑
4. Tot only this Page
5. Total of ALL CRO -1210 Pages
(This line must be on line 6 of Detailed Sunrmnry Page C'I?O-11
/'/J/1 I1lll air c
Add ❑ .Remove
I. Job Title/Profession d. Cn111llelllf
O\1CL c ss,'1CcI((
c.Employer'sppName/Specific Field I-l+l.x�"^—rler 0?
Ci U 1 1N� N 1 i I Election Sim to Date
1 � IVSNU
on J. Date (mMdd/yyyy) k Amoumt
u-cC $ (n7. GYM
$ ) 5 cv
_ S �-,� q
Odd ❑ Remove
I. Job Title/Profession Id. Comments
e. Election Sum to Date
$
I J. Date (mm/dd/yyyy) k Amount
ee - -q1t3lAva5 $-
�
S
Add LJ Rennx-c
b. Jobfillr/I'lotco>i,u,
d. Comy1meenntrs�}�`'
1 ' I 64
c. Employer's Name(Spednc
Field ✓a
�x
e. Election Stun to Date
$ 31(,60
ion
j. Date (mmldd/yyyy)
k Amount
COV)
b` b
bw
$ a5 cry
$ . o
$ al a8, yt
Amendment
Contributions from Individuals pg _L of � 0 Yet 13 No
Use this form to report individual contributions over $50 or contributions under $50 if form CRO 1205 is not used
1. Corn"ttee Full Name (;in(] Fluid il nplAic:dfle)
Y-
2, 1D Number
3. Contributor Information [I Add El Remove
a. Full Name, Mailing Address & Phone
(include city, state, & zip)
b. job'i id,J" ok "i"n
d. Comments
L;
c. Employer's Name/Specific Field
a. Elmdon Smote Date
C.Prior
g. Account Code
It. Form of Payment
1, In -Kind Description
J. Date (mnVdd/yyyy)
L Amount
0
A
01
13
owA,36ca
13
3; Contributor Information 0 Add E3 Remove
a. Full Name, Meiling Address ", Phow
(include city, slate, & zip)
—
101\1 '
611N -
SEP 2 9 2625
b. job Title/Profession
d. Conanneras
c. Employer's NametSit"ific Field
a. Election Sum to Date
$
r. Prior
g. Account Code ,
h, V*jn.ANt!4nL—
PlIn-Kind Description
j. Date (nurdddlyyyy)
k Amount
Cl
$
0
S
3. Contributor Information 0 Add 0 Remove
a. Full Name, Mailing Address & Phone
(include city, state, & zip)
b. job Tille/Profession
d. Cournients
c. Employer's Name/Specific Field
L
e. Election Sum to Date
1'. Prior
g. Account Code
h. Form of Payment
i. In -Kind Description
J. Date (mm/ddlyyyy)
Is. Amount
❑
$
4. Total onlv this Page
99.5
7$7 -7.
5. Total of ALL CRO -1210 Pages
f This line must bran lined of Detailed Sunnnart, Page CRO4 100)
-
$ q,152,
CRO -1210 NC Slaw Board of ElecLwir, April 2007
Amendment
Contributions from Individuals Pg I of 2 ❑ Yea p No
Use this form to report individual contributions over $50 or contributions under $50 if form CRO 1205 is not used
1. Committee Full Name (and Fund if applicable)
COMMITTEE TO ELECT DANIEL FARRIS
2. ID Number
RJMQ12
3. Contributor Information 0 Add Remove
. Full Name, Mailing Address & Phone
(include city, stats, & zip)
Katherine Priebe
8008 Alma Blvd
Waxhaw, NC 28173
b. Job Title/Profession
Health Wellness
d. Comments
Contribution
c. Employer's NemelSpedfic Field
The Roots Brands
a Flection Stun to late
$ 103.20
I. Prior
g. Account Code
It. Form of Payment
L In-Hfod Deaeriptiun
J. Date (omlddfyyyy)
L Amount
❑
STRIPE
09/18/2025
$ 103.20
❑
$
3. Contributor Information Add E3 Remove
. Full Name, Mailing Address & Phone
(include city, state, & zip)
b. Job TiaetProfession
d. Comments
Owner
Contribution
Kevin Leebrick
7702 Spanish Oaks Dr.
Waxhaw, NC 28173
e. Employer's Name/Spedflc Field
MyStorageOps
`' Election sum m Date
$ 257.55
f. Prior
❑
g. Amount Code
It. Form of Payment
STRIPE
i. In -Kind Description
J. Date (mmfddlyyyy)
lc Amount
$ 257.55
08/01/2025
❑
$
❑
S
3. Contributor Information ❑ Add ❑ Remove
a. Full Name, Mailing Address & Phoneb.
(include city, state, & zip) INFNI:E
Job Title/Profession
Sales
me
d. Comments
Contribution
Jeff Hiebert 2 9 2025
5809 Florance Rd SEP
Northlake, TX 76247 D i::(—j= i\/Fn
m
e. Employer's Nse/Sped& Field
Charter
e• Election sum to Date
$ 103.20
f. -Prior—
❑
g. Account Code
h. Form of Pavment
STRIPE
i. In -Kind Description
Dole(mmlddlyyyy)
LAmount
$ 103.20
08/04/2025
❑
$
❑
$
4. Total only this Page
$ 463.95
5. Total of ALL CRO -1210 Pages
(This Has must be on line 6 of Derailed Summary Page CR0.1100)
$ ��p y3
CRO -12/0 NC state Board of Elections April 2007
Amendment - -
Contributions from Individuals Pg z of 2 0 Yea 0_ No
Use this form to reoort individual contributions over $50 or contributions under $50 if form CRO 1205 is not used
1. Committee Full Nance (and Fund if applicable)
COMMITTEE TO ELECT DANIEL FARRIS
2. In Number
RJMQI2
3. Contributor Information 13 Add E3 Remove
. Full Name, Mailing Address & Phone
(include City, state, & rip)
-
Kimberly Farris
PO Box 1003
Brea, CA 92822
b. Job Title/Profession
d. Comments
Logistics
Contribution
c. Employer's Name/Specific Held
Ex resswa
P Y
e. Election Som to Date
$ 514.50
. Prior
g. Account Code
K Form of Payment
L Un Kind Description
Date (mmlddlyyyy)
k Amount
❑
STRIPE
08/18/2025
$ 514.50
❑
$
❑
$
3. Contributor Information Add E3 Remove
. Full Name, Mailing Address & Phone
(Include City, state, & rip)
b. Job Title/Profession
d. Comments
Sales
Contribution
Teresa Carroll
3304 Collins Rd.
Waxhaw, NC 28173
a �Ura�v1
c. Employer's NameApee{Dc Field
JavaJeffs Coffee
e. inn Sum to Date
$ 1,000.00
. Prior
g. Accomtt Code
1h. Form of Payment,
Date (®Iddfy'yyy)
It. Amomt
❑
-
STRIPE
2 9 2025
08/07/2025
$ 1,000.00
❑
$
3. Contributor Information ❑ Add ❑ Remove
a. Full Name, Mailing Address & Phone
(include city, state,zip)
b. Job IldelProfession
d. Comments
(y,,�
C -0L/ 1tX'hM
0T.s
`&
LIWS Uy'�y`
WwcWA'64 nC agvo3'
c. Employer's Name/Specific FkW
' r%
e. Election Sam to Date
$
f.Prior
❑
g. Amount Code
b. Form of Payment
i. In -Kind Description
Date (medibloyyy)
It. Amount
C-C,S1N
02vok/aC96
$ boo.co
❑
$
❑
$
4. Total only this Page
$ . 6
5. Total of ALL CRO -1210 Pages
(This fine mast be om fine 6 of Derailed Summary Page CRO -1100)
-
CRO -1210 NC State Board of Elections April 2007
Amendment
Disbursements Pg _ of _ ❑ Yes i] No
Use this form to report expenditures from the committee for operating expenses, contributions to candidaie/poli_tical
,-nmmittrec and rnnrdinated narry exnenditures
1. o ttee dens app ca )
umber
COMMITTEE TO ELECT DANIEL FARRIS I
RJMQ12
3. Type of Dfabarmnent Wkwe use separate CRO -1310 forms for each tvpt of Disbursement )
Operating Fz enses El Contributions to Candidates/Political Committees 13Coordinated Party Expenditures
4. Payee Information 13 Add E3 Remove
a. Full Name, Mailing Address & Phone
(include city, state, & )
It. Coordinated Committee Name
d. Comments
SIGNS.COM
8000 Haskell Ave.
Van Nuys, CA 91406
c. Level Registered (specify)
Federal U County:
❑state E3 Municipality:
e. Election Sam to Date
$ 1,212.46
E Account Code g. Form of Payment
d purpose Code
L Date (rmlddlyyyy) j. Amount It. Required Remarlo
1240 Debit
1
B
08/25/2025 $ 606.23 WXWTeamsi
1240 Debit
B
09/16/2025 $ 606.23 WXWTeamsi n
4. Payee Information Add Remove
. Full Name, Mailing Address & Phone
(include city, state, & rip)
SIGNS.COM
8000 Haskell Ave.
Van Nuys, CA 91406
b. Coordinated Committee Name
it. Comments
c. Level Registered (speckly)
Federal County:
❑ State ® Municipality:
&FJectionSumtoDate _
$ 606.23
. Account Code
g. Form of Payment
JIL Purpose Cade
IL Date (muddd/yyyy)
0. Amount
1k. Required Remarks
1240
Debit
B
1 09/08/2025
$ 606.23
DF4WXWsign
4. Payee Information U Add U Remove
. Full Name, Mailing Address & Phone
(include city, state, & sip) I =C-
b. Coordinated Committee Name
d. Comments
— _
.... •
SEP 2 9 2025
RECE.1VED
c. Level Registered (Specify)
Federal County:
[3 State ❑ Municipality:
e.MeeaonSmto Date
$
. Account Code
g. Form of Payment h. Pmpoee Cade It Date (nmadd/yyyy)
U. Amount
IL Required Remarks
is
S
5. Total only this Page
$ 1,818.69
6. Total of ALL CRO -1310 Pages
(This line goes in line 13a of Detailed .Summary Page CRO -1100 if Operating Expenses)
(This line goes in line 131, of Detailed .Summary Page CRO -1100 if Contrib to Candidates/Political Comm)
(This line goes in line 13'arty Expenditures)
$ 1,818.69
7. Purpose Codes (List detailed expenditure code in (h.) above)
A* - Media B* - Printing C* - Fundraising D - To Another Candidate
E - Salaries F* - Equipment G - Political Party H* - Holding Public Office Expenses
I - Postage J - Penalties K* - Office Expenses Q* - Donation to Legal Expense Fund
0* Other
* Codes rectuire detailed ex lanation in re uired remarks field W
CRO -1110 NC State Board of Elections December 2009
Amendment
Aggregated Non -Media Expenditures Page ---of ❑ Yes ❑ No
Optional form used to resort NC Non -Media Expenditures of $50 or less.
1. Committee tW Now = Fund if ap
tmt r
—
OMMITTEE TO ELECT DANIEL FARRIS
RJMQ12
3. Payee Information
. Amend
b. Account Code
c. Form of Payment
d. Purpose Code
e. Date (m m/dd/yyyy)
L Amomt
& Required Remarks
EAdd
$
❑ Remove
NkMR
STRIPE
O
08/01/2025
7.77
CC Processing
Add
❑ Remove
NkMR
STRIPE
O
08/04/2025
$ 3.29
CC Processing
Er Add
❑ Remove
NkMR
STRIPE
O
08/07/2025
$ 29.30
CC Processing
Add
❑ Remove
NkMR
STRIPE
O
08/09/2025
$ 21.75
CC Processing
Add
❑ Remove
NkMR
STRIPE
008/18/2025
$ 15.23
CC Processing
Er Add
❑ Remove
NkMR
STRIPE
O
09/18/2025
$ 3.29
CC Processing
Add
❑ Remove
1240
Debit
K
08/23/2025
$ 29.00
WebPartner
Aad
❑ Remove
1240
K
08/23/2025
$ 29.00
WebPartner
Add
$
❑ Remove
El Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ Remove
$
$
r
lJ N i.
$
;�AlJp;
Z 9
�25
Add
$
❑ Remove
Add
$
❑ Remove
Add
$
❑ R
El Add
$
❑ Remove
4. Total only this Page
$ 138.63
5. Total of ALL CRO -1315 Pages
$
(This Erse must be on line 14 o Detailed Summa Pa a CRO -1100)
138.63
Purpose Codes (List detailedndi ure code in (d) above)
B* - Printing C* - Fundraising D - To Another Candidate
E - Salaries F* - Equipment G - Political Party H* - Holding Public Office Expenses
I - Postage J - Penalties K* - Office Expenses Q* - Donations to Legal Expense Fund
O* - Other
* Codes require detailed explanation in required remarks field
RO-1315 NC State Board of Elections December 2009
Amendment
In -Kind Contributions Pg I of 2 ❑ Yes ❑ No
Use this forrn to report non-na netary contributions, donations, goods or services provided to the committee w tund.
Use CRO -1215 if In -Kind Contributions were or will be refunded within 7 days.
L Committee Full Name (and Fund if a ble)
12. ID Number
COMMITTEE TO ELECT DANIEL FARRIS
RJMQI?
3. Contributor Information E3 Add El Remove
a. Full Name, Mailing Address & Phone
(include city, state, & zip) _ _
Errol Wedra
4344 Oxford Mill Rd.
Waxhaw, NC 28173
b. Type of Contributor
c. Comments
9 Individual
❑ Candidate
❑ Puny
❑ PAC
❑ Referendum
❑ Other Receipt Source
Lawson Meet -Up
d. Election Sam to Date
$ 105.40
e. Description
L Date (mmlddlyyyy)
g. Fair Market Amount
Event Space
09/17/2025
$ 67.00
Refreshments
$ 15.00
Literature
$ 23.40
3. Contributor Information 0 Add Remove
a. Full Name, Mailing Address & Phone
(include city, state, &zip)
b. Type of Contributor
c Comments
Inverness Meet -Up
Individual
❑ Candidate
❑ Party
❑ PAC
❑ Referendum
❑ Other Receipt Source
Susan Marciniak
113 Somerled Way
Waxhaw, NC 28173
d. Ekcdon Sam to Date
$ 45.00
. Description
Event Space
L Date (mmiditM)
It. Fair Market Amount
09/13/2025
$ 30.00
Refreshments
$ 15.00
$
3. Contributor Information ❑ Add ❑ Remove
. Full Name, Mailing Address & Phone SEP 2 9 20
(include city, state, & zip)
Committee To Elect Michael Ep6C E IV E D
3402 Taviston Dr.
Waxhaw, NC 28173
b. Type of Contributor
C. Comments
Individual
0 � daSe
❑ PAc
❑ Referendum
❑ Other Receipt Source
Contribution
d. Election Sum to Date
$ 34.00
e. Description
L Date (mmlddlyyyy)
It. Fair Market Amount
Booth Rental (WXW Faun Market)
09/23/2025
$ 25.00
Literature (Printing)
09/23/2025
$ 9.00
4. Total only this Page
$ 184.40
5. Total of ALL CRO -1510 Pages
(This line must be on line 17 of Detailed Summary Page CR0.1100)
$ 349.98
CRO -1510 NC State Board of Elections December 20W
Amendment
In -Kind Contributions Pg z of 2 0 Yes _0 No
Use this form to report non -monetary contributions, donations, goods or services provided to the committee or fund.
Use CRO -1215 if In -Kind Contributions were or will be refunded within 7 da s.
1. Committee Fdl Name and FmW if applicable)
2. m Number
COMMITTEE TO ELECT DANIEL FARRIS RJMQ12
. Contributor Information Add El Remove
. Full Name, Malting Address & Phone b. Type of Contributor c. Comments
(include city, state, & zip) Q Individual
❑ Candidate Literature & T -Shirts
Committee To Elect John Gemignani ❑ Party
1112 Ridge Haven Rd. ❑ PAC
Waxhaw, NC 28173 ❑ Referendum d. Election Som to Date
❑ Other Receipt Source $ 165.58
e. Description
f. Date (mmldd/yyyy)
g. Fair Mares Amount
09/23/2025
$ 122.25
Campaign Literature (Palm Card, Business Card)
Campaign T -Shirt:
09/23/2025
$ 43.33
$
3. Contributor Information 0 Add 0 Remove
. Full Name, Mailing Address & Phone
It. Type of Contributor
c. Comments
E3 Individual-
(include city, state, & rip)
❑ Candidate
❑ "any
❑ PAC
❑ Referendum
d. Election Sum to Date
❑ Other Receipt Source
$
e. Description
C Date (mm/dd/yyyy)
g. Fair Market Amount
$
3. Contributor Inforntaiion 0 Add 0 Remove
a. Full Name, Mailing Address &Phoce f
linclude city, state, & zip) 1Fp 2 9 2�Z:
b. Type of Contributor
c. Comments
Individual
_-- — — _ -
`,GENED
® Candidate
❑ Party
❑ PAC
❑ Referendum
d. Election Sum to Date
❑ Other Receipt Source
$
. Description
E Date (mm/dd/yyyy)
& Fair Market Aomunt
$
4. Total only this Page
$ 165.58
5. Total of ALL CRO -1510 Pages
(This line must be on line I7 of Derailed Summary Page CRO -1100)
$
349.98
CRO -1$10 NC State Board of Elections December 2007