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~('111.1)111 Ii I' h~)l,I ) <br /> :~crieclule B- gyp® or Print In Ink, <br /> ~r. t; ,; SheettAmounts may be r~unded Statement covers period <br /> ~_on..nua..on. ,o.ho,. <br /> Payments and Contributions f,om <br /> (Other Than Loans) Made <br /> ~ ~ ~FICEHOL~R OR C~DATE ~D C~TR~LED CO~I~EE: I D. ~M~R <br /> NAME AND A~RE~ ~ PAYEE. CREDIT~ ~ RECIPIENT ~ C~1RIBUTION <br /> (IF C~I~EE, ~ ~ ~O C~E'S N~ ~D ~, ENTER I D ~R ~, <br /> F ~ I D NU~R H~ ~EN ~ED, EN~R 1~R'S ~ & ~SS} : C~ ~ ~RIPTI~ OF PAY~NT ~T PAID <br /> <br /> SUBTOTAL $ <br /> <br /> <br />