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497 Contribution Report Amounts may be rounded to whole dollars. 497 CONTRIBUTION REPORT
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EAEA GO�PHONE NUMBER ,
TY
No. of Pages i
DFULL
NAME. STREETADDRESSAND ZIP CODE OF CONTRIBUTOR
CONTRIBUTOR
CODE
IF AN INDIVIDUAL,
ENTER OCCUPATION AND EMPLOYER
Si WELOYED. EWER rvFME or a EFISS
AMOUNT
RECEIVED
(IF COMMITTEE. ALSO ENTER I O rvVMi
(IF
tQPa;kIif.
❑ IND
I 000
��� ,,, / / /COM
DA OTH
❑Check if Loan
PTV
❑ SCC
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e
Pmvlee mlerem reIe
�p p
\AaA'Cunc �CJKD
❑ IND
Ilo0�'
pp
U
,pnaa
❑COM
;OTH
❑Check if Loan
❑ PTV
z
❑SCC
Pro.me :Harem reIe
❑ IND
❑ COM
❑ OTH
❑ Check if Loan
❑ PTY
❑ SCC
Pmvma immram or-
-Contributor Codes
IND - Individual
COM - Recipient Committee (other Man PTY or SCC)
OTH - Other (e.g.. business entity)
Reason Tor Tamenu.nem.
PTY - Political Parry
SCC- Small Contributor Cpmmdtee J
FPPC Form 497 (March12011)
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