HomeMy WebLinkAboutForm 497- Yes on Measure D (2016-05-03)497 Contribution Report Amounts may be rounded to whole dollars.
Report No. ___ 4 __ _
NAME OF FILER Date of
Committee to Support San Rafael Libraries -Yes on Measure D This Filing __ 5_-_3_-1_6 __
----~=-~~~~----------~~~=-----------------~ AREA CODE/PHONE NUMBER 1.0 . NUMBER (if applica ble)
415-755-2178 1381895
STREET ADDRESS o Amendment
to Report No. ____ __ 1000 4th St., Suite 600
-CI-TY------------------S"::":T.=A=:rE=-------::Z,.."IP,..,C:-:Oc::D=E------i (explain below)
San Rafael CA 94901 No.ofPages __ ~1 __ _
1. Contribution(s) Received
DATE FULL NAME , STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR
RECEIVED (IF COMMITIEE. ALSO ENTER 1.0 . NUMBER) CODE *
San Rafael Public Library Foundation D INO 1000 4th St. Suite 600
San Rafael, CA 94901 D COM
May 2 , 2016 P,O. Box 151541 ~ OTH
San Rafael, CA 94915-1541 D PTY
D sec
D INO
D COM
D OTH
D PTY
D sec
D INO
D COM
D OTH
D PTY
D sec
ReasonfurAmendment _________________________________ _
CITY CLERK'S 0
IF AN INDIVIDUAL,
ENTER OCCUPATION AND EMPLOYER
(IF SELF-EMPLOYED, ENTER NAME OF BUSINESS)
··Contributor Codes
INO -Individual
AMOUNT
RECEIVED
$5,000
o Check if Loan
%
Provide interest rate
o Check if Loan
%
Provide interest rate
o Check if Loan
%
Prov ide 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/20161
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www.fppc.ca.gov