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Form 497- Yes on Measure D (2016-05-13)497 Contribution Report Amounts may be rounded to whole dollars. OF Committee to Support San Rafael Libraries -Yes on Measure D AREACOD8PHONENUMBER 415-446-4222 1000 Fourth Street, Suite 600 !.D. NUMBER (ifapplicab/e) 1383895 Date of This Filing __ 5_/1_3_/2_0_1_6_ Report No. ___ 5 __ _ o Amendment to Report No. ____ _ "::"C=ITY::-:------------------=;;:---=:-;;-;::;::';:"E------I (explain below) San Rafael CA 94901 No.ofPages ___ 1~ __ 1. Contribution(s) Received FULL NAME. STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR DATE RECEIVED (IF COMMITTEE. AlSO ENTER 1.0. NUMBER) CODE * Service Employees Intemational Union Local 1021 Issues PAC 0 (NO 555 Capitol Mall, Suite 1425 [g] COM 5/12/2016 Sacramento, CA 95814 0 OTH ID #1296947 0 PTY 0 sec 0 (NO 0 COM 0 OTH 0 PTY 0 sec 0 (NO 0 COM 0 OTH 0 PTY 0 sec ReasonfurAmendment _________________________________ _ CITY CLERK'S 0 IF AN INDIVIDUAL. ENTER OCCUPATION AND EMPLOYER (IF SELF-EMPLOYEO. ENTER NAME OF BUSINESS) "Contributor Codes INO -Individual AMOUNT RECEIVED 5,000 o Check if Loan % Provide interest rate o Check if Loan % Provide inlerest rate o Check if Loan % Provide interest rete 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/20i6) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov