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I certify that the following statements are true and correct:

• This contribution is made from my own funds and not those of another.

• This contribution is not made from the general treasury funds of a corporation, business entity, NC registered Lobbyists, labor unions professional association, or insurance company.

• This contribution is made on my personal credit card for which I have a legal obligation to pay and is not made on a corporate credit card.

For any Joint Contribution from a Joint Account, please provide the additional full name, employer and occupation for the donor.