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NAME OFF FILER
497 CONTRIBUTION REPORT
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Date of
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AREA CODEICP3HGfN/E NUMBER
I.D. NUM (if applicable)
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Report No.
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STREET ADDRESS
1. Contribution(s)
Received
DATE
RECEIVED
FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR
(IF COMMITTEE, ALSO ENTER I.C. NUMBER)
CONTRIBUTOR
*
CODE
IF AN INDIVIDUAL,
ENTER OCCUPATION AND EMPLOYER
AMOUNT
(IF SELF - EMPLOYED, ENTER NAME OF BUSINESS)
RECEIVED
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Reason for Amendment:
— 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 (March /2011)
FPPC Toll -Free Helpline: 8661ASK -FPPC (8661275 -3772)
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