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Late Contribution TVp, or print inink. LATE CONTRIBUTION REPO~f <br /> Report Amounts may be rounded . <br /> -- to whole dollars. C~ate Sram p <br /> SEE INSTRUCTIONS ON REVERSE <br /> <br /> Filer Must Check Applicable Box: Complete <br /> Part: Fo, Official Use Only <br /> /~ Reporting Late Contribution(s) Received: I <br /> I-I Repofling Late Contribution(s) Made: II <br /> ESi <br /> NAME Of FILER ' ' STREET ADDR ' <br /> <br /> I Late Contribution(s) Received From: II Late Contribution(s) Made To: <br /> NAME to. NUMmR ¢#dV,~c~eJ NAME Of CANDIDATE OR COMMITTEE <br /> I.O. <br /> <br /> /,,/~ / .... ~- , / , /, Is .... /., <br /> <br /> A~SS C~Y STATE Z~ C~E lO~SS C~Y <br /> <br /> ~C~AT~M~OY(A M NAME M I~IMSS t $ELf-EM~QYE~ i~M) MFICE ~HT BY ~N~AIE ~ ~LL~ ~E'E RAND J~ <br /> <br /> NAME t.O. N~o[I Of.~) NAME ~ <br /> A~$S CITY STATE Z~ C~E <br /> AD.SS Cll Y SLAVE Z~ CODE <br /> <br />C~ OCCUFATI0fl/IMPLOYER OR NAME OF IUMI~SS If SELI.E MPLOYI D(If 4pp/Lk~ble) OFFICE SO.HI BY ~N~DATE ~ BALL01 K.AEITE~ AND <br />I <br /> <br /> ' I~1 S I I:: t I <br /> t~ ~ll~ ~QUIED IQ Il PROV~ED lO Y~ PUR~ANI lO Ifil INI~AT~ P~ES ACT ~ 1t17, SEE INFORMATION MANUAl ON CAMPAIGN OlS(L~UR[ PIOV~ION$ ~t lfl~LllJC l[ l(l~ ACI <br />o <br /> <br /> <br />