Loading...
Martin,Steve_2022-2nd-qtrAmendment Disclosure Report Cover I ❑ ves ® No Use this form for general report and committee information, must be signed and submitted along with other detailed forms. Do not use this form to undate information 1. Committee Information a. Full Name c. In Number Committee to Elect Steve Martin b. Mailing Address (include City, State and Zip Code) tL Date Filed P.O. Box 1593 07/05/2022 Matthews, NC 28106 e. Phone Number 704-254-4789 2. Report Year 3. Period Start Date (mm/dd/yyj 4. Period End Date mm/dd! 5. Treasurer Full Name ....— _ _ >0 » 0 OI '_071_ 2_ 06/30/2022 Stephen D. Martin 6. Type of Committee (Check One) 9. Type of Re ort only one e of re ort om one tate ® Candidate Campaign ❑ Party Municipal State/County Referendum ❑ Organizational ❑ Organizational ❑ Organizational ❑ PAC ❑ Referendum Independent ❑ Joint Fundmiser ❑ Expenditure ❑ Thirty-five day Quarterly ❑ Pre -referendum ❑ Legal F%pense Fund ❑ Pre-primary ❑ Pre-election ❑ First ® Second ❑ Final ❑ Supplemental Final 7. Type of Fund f applicable. check one) ❑ 'Booster Fund" ❑ Building Fund ❑ Pre -runoff ❑ Third ❑ Annual Semi-annual ❑ Fourth ❑ Special ❑ Mid Year Semi-annual ❑ other: ❑ Year End ❑ Mid Year 10. Special Report Name ❑ Final ❑ Special ❑ Year End ❑ Final ❑ Special 8. Number of Fundraisers this Report 0 11. Account Information 11. Account Information a. Financial Institutioa Full Name a. Financial Institution Full Name Wells Faro Bank, NA It. Pur c. Account Code L Purpose c. Account Code all campaign expenses A JUL 0 5 2022 d. Period Begin Balance d. Period Begin Balance $ 2,922.61 Union Co. Elections $ 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 prohibi d or other non -disclosed funds. I further certify that this report is complete, true and correct and that I have been trained by the NCSt f Elections. Stephen D. Martin 07/05/2022 Printed Name of Signer Signature of Ap ted Treasurer Date FOR OFFICE USE ONLY Date Received: g a Employee: Delivery Method ❑ Normal Mail Date Postmarked: Employee: �❑ Registered Mail Hand Delivered Date Scanned: Employee: E] Electronically Filed ❑ Signer has not received Date Data Entered: Employee: mandatory 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 ❑ Nes ® No Use this form to summarize all disclosure reporting forms and to total monetary information. 1. Committee Full Name and Fund if applicable) 2. Type of Report 3. ID Number Committee to Elect Steve Martin Organizational Start of Election Cycle: January 1, 2019 Total this Total this Reporting Period Election Cycle 4) Cash on Hand at Start $ 2,922.61 $ 0.00 V&EH"TS 5) Aggiegated Contributions from Individuals (CRO -1205) $ 364.66 $ 1,118.98 6) Contributions from Individuals (CRO -1210) $ 563.92 $ 4,554.11 7) Contributions from Political Party Committees (CRO -1110) $ 0.00 $ 50.00 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 Ila) Interest on Bank Accounts (CRO -1150) $ I lb) Contributions from Not -for -Profit Organizations (CRO -1250) Ile) Outside Sources of Income (CRO -1150) JUL 0 b 2022 lid) Legal Expense Fund— Other Sources (CRO -1170) 11) 11 e) Exempt Purchase Price Sales (CRO -1265) $ 12) TOTAL RECEIPTS (Addlines5.6.7.8. 9. 10, Ila, 11b. /le. Ildmd lie) $ 928.58 $ 5,723.09 13) Disbursements 13a) Operating Expenditures (CRO -1310) $ 644.02 $ 1,409.13 13b) Contributions to Candidates/Political Committees (CRO -1310) $ 168.00 $ 168.00 13c) Coordinated Party Expenditures (CRO -1310) $ $ 14) Aggregated Non -Media Expenditures (CRO -1315) $ 11.60 $ 23.20 15) Loan Repayments (CRO -1420) $ $ 16) Refunds/Reimbursements From the Committee (CRO -1310) $ $ 17) In -Kind Contributions (CRO -1510) $ 118.70 $ 1,213.89 18) TOTAL EXPENDITURES (Add lines 13a, 13b, 134, 14, 15,16 and 17) $ 942.32 $ 2,814.22 19) Cash on Hand at End (Addline, a and 11 together, then subtract line 18) $ 2,908.87 $ 2,908.87 A 20) Non-Monctan Gifts Given to Other Committees (CRO -1330) $ 21) Outstanding Loans (incl. ones from other campaigns) (CRO -1430) $ 22) Debts and Obligations owed By the Committee (CRO -1610) S 23) Debts and Obligations owed To the Committee (CRO -1620) $ 24) Account Transfers Within the Committee (CRO -1710) $ 25) Administrative Support (CRO -1710) $ S 26) Forgiven Loans (CRO -1440) $ S 27) 48 -Hour Notice Reports Sum (CRO -2220) $ S 28) Contributions to be Refunded (CRO -1115) S $ CRO -1100 NC State Board of Elections August 2008 Amendment Aggregated Contributions from Individuals Page I of I ❑ Yes ® No Optional firm used to report NC Contributions From Individuals of $50 or less 1. Committee Full Name and Fund ifapplicable) 2. ID Number Comminec to Elect Steve Martin 3. Contributor Information a. Amend 6. .Account Code C. Form of Payment d. In -Kind Description e. Date mm/dd/ I. Amount Add A electronic 05/01/2022 $ 50.00 Remove Ada A electronic 05/05/2022 $ 6.00 Remove Add A electronic 05/06/2022 $ 10.00 Remove Add A electronic 05/092022 $ 50.00 Remove Add $ Remove ED Add A electronic 05/19/2022 $ 5.00 Remove Add A electronic 05/25/2022 $ 3.00 Remove ❑ Add 4 electronic 05/26/2022 $ 20.22 Remove Add A electronic 05/26/2022 $ 20.22 Remove Add A electronic 05/26/2022 $ 25.00 Remove Add A electronic 05/272022 $ 50.00 Remove Add $ Remove Add A check 05/272022 $ 50.00 ❑ Remove ❑ Add A electronic 05292022 $ 10.00 ❑ Remove Add A electronic 06/012022 $ 20.22 ❑ Remove Add A electronic 06/052022 $ 5.00 Remove Add A electronic 06/06/2022 $ 10.00 Remove Add A electronic 06/19/2022 $ 5.00 Remove Add A electronic 06252022 $ 3.00 Remove Add A electronic 06/292022 $ 10.00 Remove Add $ Remove Add $ Remove 4. Total only this Page $ 397.88 5. Total of ALL CRO -1205 Pages (This line muse be on fine 5 of Detailed Summary Page CRO -1100) $ 397.88 CRO -1205 NC State Board of Elections April 2007 Amendment Contributions from Individuals Pg i of 3 ❑ Its ® 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) 2,1D Number Commitee to Elect Steve Martin 3. Contributor Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) b. Job Title/Profession d. Comments Not Employed Evelyn Maben-Hall 1 176 Woodwinds DT Waxhaw, NC 28173 c. Employer's Name/Speclac Field Not Employed e. Election Sum to Date $ 105.22 E Prior g. Account Code It. Form of Payment I. In -Kind Description j. Date (mm/dd/yyyy) L Amount ❑ A electronic 05/15/2022 $ 20.22 ❑ $ ❑ $ 3. Contributor Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) It. Job Title/Profession d. Comments Not Employed Heather Old land 7221 Yellowhom Trail Waxhaw, NC 28173 e. Employer's Name/Specific Field Not Employed e. Election Sum to Date $ 100.00 E Prior g. Account Code h. Form of Payment i. In -Kind Description j. Date (mm/dd/yyyy) h. Amount ❑ A electronic 05/26/2022 $ 100.00 ❑ $ ❑ $ 3. Contributor Information ❑ Add ❑ Remove o a. Full Name, Mailing Address & Phone (include city, state, &zip) It. Job Title/Professiou o e Not Employed JUL 05 2022 Union Co. Elections Evelyn Maben-Hall 1176 Woodwinds Dr. Waxhaw, NC 28173 e. Employer's Name/Specific Field Not Employed e. Election Sum to Date $ 130.22 E Prior g. Account Code h. Form of Payment I. In -Kind Description j. Date (mm/dd/yyyy) K Amount ❑ A electronic 05/27/2022 $ 25.00 ❑ $ ❑ $ 4. Total only this Page $ 145.22 5. Total of ALL CRO -1210 Pages $ 563.92 (This line must be on Arte 6 of Demiled Summar Page CRO -1100) CRO -1210 \l State Board of Elections April 2007 Amendment Contributions from Individuals Pg 2 or J ❑ Yes ® No Use this form to report individual contributions over $5t1 or contributions under $50 if form CRO 1205 is not used 1. Committee Full Name and Fund ifs linable) 2. ID Number Committee to Elect Steve Martin 3. Contributor Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, sate, & zip) b. Job Title/Profession d. Comments Physician Susan Antle 2034 Belle Grove Dr. Marvin, NC 28173 c. Employer's Name/Specific Field Atrium e. Election Sum to Date $ 100.00 f. Prior g. Account Code Is. Form of Payment i. In -Kind Description J. Date (mm/dd/yyyy) k. Amount ❑ A electronic 06/09/2022 $ 100.00 ❑ $ ❑ $ 3. Contributor Information ❑ Add ❑ Remove a. Full Name, .Mailing Address & Phone (include city, sate, & zip) b. Job Title/Profession d. Comments Executive Samir Mehta 8509 English Turn Ln Waxhaw, NC 28173 c. Employer's Name/Specific Field Collins Aerospace e. Election Sum to Date $ 100.00 E Prior g. Account Code It. Form of Payment i. In -Kind Description J. Date (mm/dd/yyyy) k. Amount ❑ A electronic 06/13/2022 $ 100.00 ❑ $ 3. Contributor Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone b. Job Title/Profession (include city, sate, & zip) Riding Instructor Andrea Guzinski JUL 05 2022 2620 Waxhaw Marvin Rd c. Employer's Name/Specific Field Waxhaw, NC 28173 Self -Employed Union Co. Elprtinnc: e. ee on am o $ 100.00 E Prior g. Account Code h. Form of Payment i. In -Kind Description j. Date (mm/dd/yyyy) It. Amount ❑ A electronic 06/19/2022 $ 100.00 ❑ $ ❑ $ 4. Total only this Page $ 300.00 5. Total of ALL CRO -1210 Pages $ 563.92 (This line must be online 6 of Detailed .Summmn Page CRO -1100) CRO -1210 \C State Board of i_lections April 2007 Amendment Contributions from Individuals 1. 111 3 of 3 ❑ Yes ® No Use this form to rep,ut Individual contributions over $50 or contributions under S50 if form CRO 1205 is not used 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Steve Martin 3. Contributor Information ❑ Add ❑ Remove a. Full Name. Mailing Address & Phone (include city, state, & zip) h..luh 1 ide/Prufescion d. Comments Not Employed Stephen D. Martin 405 Alueio Ct. Wesley Chapel, NC 28104 e. Employer's Name/Specific Field Not Employed e. Election Sum to Date $ 1,323.89 L Prior it. Account Code It. Form of Payment I. to -Kind Description j. Date (mm/dd/yyyy) k Amount ❑ see 1510 $ 118.70 ❑ C ❑ ti 3. Contributor Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) It. Job Title/Profession d. Comments c. Employer's Name/Specific Field e. Election Sum to Date $ E Prior g. Account Code It. Form of Payment i. In -Kind Description j. Date (mm/dd/yyyy) k. Amount ❑ $ ❑ $ ❑ $ 3. Contributor Information ❑ Add ❑ Remove a. Full Name, Mailing Address & Phone (include city, state, & zip) It. Job Title/Profession I Si-ii�•J;' � p •, JUL 0 5 2022 lunion CO. LlBGi1011S c. Employer's Name/Specific Field e. Election Sum to Date $ E Prior g. Account Code h. Form of Payment 1. In -Kind Description J. Date (mm/dd/yyyy) h. Amount ❑ $ ❑ $ D $ 4. Total only this Page $ 118.70 5. Total of ALL CRO -1210 Pages $ 563.92 (This line must he on line h of Derailed Sunsmary Page. CRO -1100) ( RO-1210 NC State Board of Hections April 2007 Amendment Disbursements Pg 1 of 2 ❑ Yes ® No Use this form to report expenditures from the committee for; operating expenses, contributions to candidate/political committees and coordinated party expenditures. 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Steve Martin 3. Type of Disbursement Please use separate CRO -1310 forng for each type of Disbursement ® UperalIF) g I[\pcnec, ❑ Cnnlnhm iums W C nndid,nc, I'ohn ,d Conuoiuec. ❑ l onrdinated Pam I \pcnd lure. 4. Payee Information Add El Remove a. Full Name. )tailing Address & Phone include city. state & a b. Coordinated Committee Name d. Comments AClBlue, LLC 366 Summer St Somerville, MA 02114 c. f.evel Registered (Specify) ❑ Federal ❑ County: El State ❑ Municipality: e. Election Sum to Date $ 63.17 f. Account Code g. Form of Payment b. Purpose Code L Date (mm/dd/yyyy) J. Amount k Required Remarks A debit C 05/04/2022 $18,96 fees $ 4. Payee Information rl Add Remove a. Full Name, Mailing Address & Phone include city, state & zip) b. Coordinated Committee Name d. Comments e. Election Sum to Date $ 55.44 Vantiv, LLC 38500 Governors Hall Dr. Symmes Township, OH 45249 c. level Registered (Specify) ❑ Federal ❑ County: ❑ State ❑ Municipality: 4 Account Code g. Form of Payment h. Purpose Code L Date (mm/dd/yyyy) J. Amount k Required Remarks A debit C 05/10/2022 $27.00 CC fees 4. Payee Information Add Remove a. Full Name, Mailing Address & Phone (include city, state & b. Coordinated Committee Name � —4 JUL 0 5 2022 KT Print & Design 1323 W. Roosevelt Blvd. Monroe, NC 28110 c. Level Registered (Specify) ❑ Federal ❑ County: ❑ State ❑ Municipality: $ 469.70 E Account Cork Z. Form of Payment it. Purpose Code L Date (mmlddlyyyy) j. Amount j Is. Required Remarks A debit B 05/25/2022 $469.70 Palm cards 5. Total only this Pae $ 515.66 6. Total of ALL CRO -1310 Pages (Tlds line goes in line l3a of Delailed .SummarPage CRO -11(00 if Operating Expenses) (This line goes in line 136 of Detailed Summary Page CRO -1100 if Contrib to CandidateslPolitical Comm) $ 644.02 (This line goes in line 13c of Detailed Summar' Page CRO -1100 if Coordinated Party Expenditures) 7. Pu se Codes(List detailed expenditure code in above A* - Media B* - Printing C* - Fundraising D - I o Another Candidate E - Salaries F* - Equipment G - Political Patty H* - Holding Public Office Expenses I - Postage J - Penalties K* - Office Expenses Q* - Donation to Legal Expense Fund O* - Other * Codes require detailed explanation in required remarks field k CRO -1310 NC State Board of Elections December 2009 \mr odui enl Disbursements Pg z or z ❑ les Use this form to report expenditures from the committee for; operating expenses, contributions to candidate political committees and coordinated part% expenditures. 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect SteNe Martin 3. Type of Disbursement lease use separate CRO -1310 forim for each type of Disbursement. ® Operating I' penses ❑ Contributions In l andidaies Polilical l untmille" ❑ l uurdinaled Pam i ependnurc+ 4. Payee Information Add El Remove a. Full Name, Mailing Address & Phone Include city, state, & zip) b. Coordinated Committee Name it. Camments e. Election Sum to Date $ 69.13 ActBlue, Inc. 366 Summer St Somerville, MA 02114 c. Level Registered (Specify) ❑ Federal ❑ County: ❑ State Municipality: E Account Code g. Form of Payment b. Purpose Code L Date (mm/dd/yyyy) j. Amount k. Required Remarks A debit C 06/03/2022 $5.96 fees 4. Payee Information Add Remove a. Full Name, Mailing Address & Phone include city, state ,& a b. Coordinated Committee Name d. Comments e. Election Sum to Date $ 72.17 Vantiv, LLC 38500 Governors Hall Dr. Symmes Township, OH 45249 e. Level Registered (specify) ❑ Federal County: State Municipality: L Account Code g. Form of Payment h. Purpose Code L Date (mm/ddlyyyy) J. Amount L Required Remarks A debit C 06/09/2022 $16.73 CC fees $ 4. Payee Information rl dd El Remove a. Full Name, Mailing Address & Phone include city. state & zip) b. Coordinated Committee Name it e. JUL 0 5 2022 Vistaprint 275 Wyman Street Waltham, MA 02451+ e. Level Registered (Specify) E] Federal ❑ County: State ❑ Municipality: $ 105.67 E Account Code S. Form of Payment b. Purpose Code L Date (mm/ddlyyyy) j. Amount L Required Remarks A debit B 06/21/2022 $105.67 Palm cards 5. Total only this Pae $ 128.36 6. Total of ALL CRO -1310 Pages (This Ibte goes in line 13a of Detailed SumnrurT Page CRO -1100 if Operating Expenses) (This line goes in line 13b of Detailed Summary Page CRO -1100 ijContrib to Candidutes/Polideal Comm) $ 644.02 (This line goes in line 13c ojDetailed Summory Page CRO -1100 if Coordinated Party Expenditures) 7. Purpose Codes(List detailed expenditure code in above A* - Media B* - Printing C* - Fundraising D - To Another Candidate E - Salaries F* - Equipment G - Political Pan) H* - Holding Public Office Expenses 1 - Postage J - Penalties K* - Office Expenses Q* - Donation to Legal Expense Fund O* - Other * Codes require detailed explanation in required remarks field k CRO -1310 NC State Board of Elections December 2009 Amendment Disbursements Pg t of j ❑ Yds ® No Use this forth to report expenditures from the committee for; operating expenses, contributions to candidate/political committees and coordinated party expenditures. 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Stege Martin 3. Type of Disbursement lease use separate CRO -1310 fornity for each type of Disbursement ❑ Operating Fepen,c, ® C ont n huiions to C andidmc, Pohllcal Conunates ❑ C... m inalcd Pam I_%pcnditures 4. Payee Information Add 0 Remove a. Full Name, \tailing Address & Phone include city, state & zip) b. Coordinated Committee Name d. Comments Committee to Elect Weston Burroughs 6720 Old Monroe Rd Suite B146 Indian Trail, NC 28079 c. level Registered (Specify) ❑ Federal ❑ County: ❑ State ❑ Municipality: e. Election Sam to Date $ 168.00 E Account Code g. Form of Payment h. Purpose Code L Date (mmldd/yyyy) j. Amount h. Regtdred Remarks A electronic O 05/27/2022 $168.00 Indian Trail Family Fun fees 4. Payee Information rl Add Remove a. Full Name, Mailing Address & Phone include city, state & zip) Is. Coordinated Committee Name d Comments c. t.evei Registered (Specify) ❑ Federal ❑ County: El State ❑ Municipality: e. Election Sum to Date E Account Code g. Form of Payment h. Parpose Code i. Date (mm/dd/yyyy) J. Amount K Required Remarks 4. Payee Information Add Remove a. Full Name, Mailing Address & Phone include city, stl & zip)_ b. Coordinated Committee Name d. -•; - — JUL 0 5 2022 Union Co. EI e. Level Registered (Specify) ❑ Federal ❑ County: State ❑ Municipality: e. echon um to a e $ f. Account Code g. Form of Payment h. Purpox Code L Date (mm/dd/yyyy) j. Amount k. Required Remarks $ $ 5. Total only this Pae $ 168.00 6. Total of ALL CRO -1310 Pages (77tis line goes in line 13a of Detailed.Summan' Page CRO -1100 if Operating Expenses/ (This line goes in line 136 of Detailed Summary Page CRO -1100 ifContrib to Candidates/Political Comm) $ 168.00 (This fine goes in line 13r of Detailed Summary Page CRO -1100 if Coordinated Party Expenditures) 7. Purpose Codes(List detailed expenditure code in h. above .A* - Media B* - Printing C* - Fundraising D - ib Another Candidate E - Salaries F* - Equipment G - Political Part}- H* - Holding Public Office Expenses 1 - Postage J - Penalties K* - Office Expenses Q* - Donation to Legal Expense Fund O* - Other * Codes require detailed explanation in required remarks field k CRO -1310 NC State Board of Elections December 2009 1 1 Amendment Aggregated Non -Media Expenditures Page of p Yes p Nn Optional form used to report NC Non -Media Expenditures of SAO of less. 1. Committee Full Name (and Fundif applicable) ED Number Committee to Elect Steve Martin 3. Payee Information H. Amend b. Account Code c. Form of Payment d. Purpose Code e. Date (mmtdd/yyyy I f. Amount g. Required Remarks ❑ Add ❑ Remove A debit K 06/10/2022 $11.60 postage stamps Add $ ❑ Remove Add $ ❑ Removc Add $ ❑ Remnvc \dd $ ❑ Remo,r Add $ ❑ Removr Add $ ❑ Remove Add $ Ll Remove Add $ Q Remove Add $ El Remove \dd $ ❑ Remove Add $ ❑ Remove Add $ 13 Remove Add $ 13 Remove $ Lj $ JUL 0 5 2022 FRemove Lj $ Union Co. Elections$ \dd $ ❑ Rename Add ❑ Removc 4. Total only this Page 1 511.60 5. Total of ALL CRO -1315 Pages $11.60 (This line mast he on line 14 o Detailed Summa Page CRO -/700) 6. Purpose Lis I x n i in Ba. - Printing; C* - Fundraising D - To ;\nothei 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 CRO -13/5 NC State Board of Elections December 2009 Amendment In -Kind Contributions Pg of _ ❑ Yes ® 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 days. 1. Committee Full Name and Fund if applicable) 2. ID Number Committee to Elect Steve Martin 3. Contributor Information El Add F1 Remove a. Full Name, Mailing Address & Phone (include city, state, & aip) b. Type of Contributor c. Comments ❑ Individual ® Candidate ❑ Parry ❑ PAC ❑ Referendum ❑ Other Receipt Source Stephen D. Martin 405 Alucio Ct. Wesley Chapel, NC 28104 d. Election Som to Date $ 1,217.19 e. Description f. Date (mm/dd/yyyy) g. Fair Market Amount Google Domains - website hosting 05/27/2022 $ 6.00 Google Domains - website hosting 06/27/2022 $ 6.00 Amazon - mailing envelopes 06,I6/2022 $ 106.70 3. Contributor Information Add rl Remove a. Full Name. )sailing Address & Phone (include city,state,&zip) b. Type of Contributor c. Comments ❑ Individual ❑ Candidate ❑ Parry ❑ PAC ❑ Referendum ❑ Other Receipt Source d. Election Sum to Date $ e. Description f. Date (mm/dd/yyyy) g. Fair Market Amount $ $ 3. Contributor Information FAdd ❑ Remove -' a. Full Name, )tailing Address & Phone (include city, state. &zip) h.'fype of Contributor C. Co menti ❑ Individual ❑ Candidate ❑ Part) ❑ PAC ❑ Referendum ❑ Other Receipt Source Union Co. Elections --`_ d. Election Sum to Date $ e, Description E Date (mm/dd/yyyy) g. Fair Market Amount $ 4. Total on this Pae $ 118.70 5, Total of ALL CRO -1510 Pages (This line must he on One 17 of Detailed SummaryPage CRO -1100) $ 118.70 CRO- 1510 NC State Board of Elections December 2007