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Form 497- Yes on Measure D (2016-03-10)497 Contribution Report Amounts may be rounded to whole dollars. Committee to Support San Rafael Libraries -Yes on Measure_ Date of This Filing __ 3-_1_0_-2_0_1_6_ AREA CODE/PHONE NUMBER 1.0. NUMBER (if applicable) Report No. ___ 1 __ _ 415-446-4222 STREET ADDRESS o Amendment 1000 Fourth Street, Ste. 600 to Report No. ____ _ -C-ITY-------------------=S:O=TA""':r==E=----,Z=OI=-P -=CO=-D=-E=--------i (expla in below) San Rafael CA 94901 No. of Pages ___ 1.:....-__ 1. Contribution(s} Received DATE FULL NAME. STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR RECEIVED (IF COMMmEE, ALSO ENTER 1.0 . NUMBER) CODE .. Dirck W . Brinckerhoff IXI IND D COM 3/9/2016 San Rafael, CA 94901 D OTH D PTY D SCC D INO 0 COM D OTH D PTY 0 sec D INO D COM D OTH D PTY D see ReasonfurAmendment ________________________________ _ CITY CLERK'S 0 IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER (IF SELF.EMPLOYED, ENTER NAME OF BUSINESS) Real Estate Broker HL Commercial Real Estate ··Contributor Codes INO -Individual AMOUNT RECEIVED $1,000 o Check if Loan '4 Prov ide interest rate o Check if Loan % Provide inleresl rate o Check if Loan 'Jb 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/2016) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov