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Form 497- Yes on Measure D (2016-05-02)497 Contribution Report Amounts may be rounded to whole dollars. Date of 5/2/2016 This Filing NAME OF FILER Committee to Support San Rafael Libraries -Yes on Measure D Report No. 3 AREA CODE/PHONE NUMBER 415-446-4222 1.0 . NUMBER (ifapp/icab/e) 1383895 STREET ADDRESS DAmendment 1000 Fourth Street, Suite 600 to Report No. STATE ZIP CODE (explain below) San Rafael CA 94901 No. of Pages 1 1. Contribution(s) Received FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR DATE RECEIVED (IF COMMIITEE. ALSO ENTER 1.0. NUMBER) CODE * McCullough for City Council 2015 D INO ~ COM 4/30/2016 San Rafael, CA 94901 D OTH FPPC# 1339798 D PTY D sec D INO D COM D OTH D PTY D sec D INO D COM D OTH D PTY D sec ReasonforAmendment: __________________________________________________________________ ___ ~ IF AN INDIVIDUAL, AMOUNT ENTER OCCUPATION AND EMPLOYER RECEIVED (IF SELF·EMPLOYED ENTER NAME OF BUSINESS) "Contributor Codes INO -Individual 2,500 D Check if Loan % Provide Interest rate D Check if Loan % Provide interest ra te D Check if Loan % Provide interest rate COM -Recipient Committee (other than PTY or SCC) OTH -Other (e.g., business entity) PTY -Political Party SCC -Small Contributor Committee FPPC Form 497 (Jan/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov