497 Late Contribution Report (3)497 Contribution Report
NAME OF FILER
S-Ap k
AREA CODE /PHONE NUMBER
STREETADDRESS
Date of ( 0�2 Li I1 7'
This Filing 4
Report No.
❑ Amendment
to Report No.
(explain below)
No. of Pages
497 CONTRIBUTION RFPORT
Date Stamp `y'I ,
LS � N U V
0C� 2
UPERTINO CITY CLERK
DATE
RECEIVED
FULL NAME, STREETADDRESS AND ZIP CODE OF CONTRIBUTOR
pF coMMlrra .Aso ENTER I.D. NVNtBER)
CONTRIBUTOR
*
FAN INDIVIDUAL,
ENTER OCCUPATION AND EMPLOYER AMOUNT
CODE
(IF SELF - EMPLOYED, ENTER NAME OF BUSINESS) RECEIVED
ua L
IND
�—r c �— �— 9
❑ PTY
❑ SCC
Provide interest rate
COM
�y
OTH
Check
❑ PTY
❑ if Loan
r ��ff (
✓ ��J O �, /
❑ SCC
Provide interest rate
❑ IND
❑ COM
❑ OTH
❑ Check if Loan
❑ PTY
❑ SCC
Provide interest rate
— Contributor Codes
IND — Individual
COM — Recipient Committee (other than PTY or SCC)
OTH — Other (e.g., business entity)
Reason for Amendment:
PTY — Political Party
SCC — Small Contributor Committee
FPPC Form 497 (March/2011)
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