497 Late Contribution Report (3)497 Contribution Report
NAME OF FILER
AREACODEIPHONE NUMBER
_ �
1. Conthbution(s) Received
DATE
RECEIVED
Reason for Amendment:
I.DINUMBER fitapplicable)
_ No. of Pages �_.......
FULL NAME, STREETADDRESS AND ZIP CODE OF CONTRIBUTOR
(1F COMMITTEE, ALSO Fi47ER I . NUMBER)
497 CONTRIBUTION REPORT
OCT � 5
CUPERTINO CITY CLERK
CONTRIBUTOR IF AN INDIVIDUAL, AMOUNT
CODE * ENTER OCCUPATION AND EMPLOYER RECEIVED
(IF SELF - EMPLOYED, ENTER NAME OF BUSINESS)
❑ IND
[k-c0M
❑ OTH
❑ PTY
C SCC
❑ IND
❑ COM
❑ OTH
PTY
❑ SCC
❑ IND
El COM
❑ OTH
❑ PTY
❑ SCC
❑ Check if Loan
Provide interest rate
❑ Check if Loan
Provide interest rate
❑ Check if Loan
Ok
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 (March/2011)
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