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Form 497 - Carolina Martin for San Rafael School Board Trustee 2022 10-13-22 1497 Contribution Report NAME OF FILER Carolina Martin for San Rafael City Schools District 4 2022 AREA CODE/PHONE NUMBER I.D. NUMBER (dapplicable) ( 1449397 STREET ADDRESS CITY STATE ZIP CODE Antelope CA 95843 1. Contribution(s) Received Amounts may be rounded to whole dollars. Date of This Filing 10/12/202 Report No. 10122022-1 ❑ Amendment to Report No. (explain below) No. of Pages 1 OCT 1 3 2022 ITY CLERK'S OFFI CONTRIBUTION REPORT DATE RECEIVED FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR (IF COMMIT -FEE, ALSO ENTER California Federation of Teachers COPE CONTRIBUTOR CODE IF AN INDIVIDUAL, EONANDEE, (IF ENTER ENTEROCEMPLOYENTER NAME OF BUSINESS) E AMOUNT RECEIVED 10/10/2022 1,075.00 ❑ IND Burbank, CA 91505 ❑X COM Committee ID # 741857 ❑ OTH ❑ Check if Loan In -Kind ❑ PTY ❑ JCC % Provide interest rate ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC Reason for Amendment: ❑ Check if Loan % Provide interest rate ❑ Check if Loan x Provide interest rate `Contributor Codes IND—Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY—Political Party SCC— Small Contributor Committee FPPC Form 497 (Feb/2019) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov