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Form 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 FPPC Advice: advice@fppc.ca.gov (866/275-37721 www.fppc.ca.gov