497 Contribution Report
Amounts may be rounded to whole dollars.
B
A
Date Stamp
NAME OF FILER
Date of
CALIFORNIA FORM
497
11/01/20XX
Manuel Alvarez for Mayor 20XX
This Filing
I.D. NUMBER (if applicable)
AREA CODE/PHONE NUMBER
For Official Use Only
1
707-555-6868
12344XX
Report No.
STREET ADDRESS
Amendment
225 Presley Street
to Report No.
(explain below)
CITY
STATE
ZIP CODE
1
Oakmont
CA 95443
No. of Pages
1
1. Contribution(s) Received
FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR
IF AN INDIVIDUAL,
AMOUNT CUMULATIVE
ELECTION TYPE OF
AMOUNT RECEIVED
CONTRIBUTION TYPE OF
DATE
CONTRIBUTOR
ENTER OCCUPATION AND EMPLOYER (IF SELF-EMPLOYED, ENTER NAME OF BUSINESS)
RECEIVED
CODE*
(IF COMMITTEE, ALSO ENTER I.D. NUMBER)
GENERAL
Loretta Stone 28 Hemlock Street Oakmont, CA 95434
IND COM OTH PTY SCC IND COM OTH PTY SCC IND COM OTH PTY SCC
MONETARY
$2,000
Nurse - Oakmont Hospital
10/30/XX
PRIMARY
$2,000
NON - MONETARY
Check if Loan
OTHER
%
Provide interest rate
GENERAL
MONETARY
ABC Company 220 R Street Oakmont, CA 95434
$3,000
10/30/XX
PRIMARY
$3,000
NON - MONETARY
Check if Loan
OTHER
%
Provide interest rate
GENERAL
MONETARY
NON - MONETARY Completing the Form 497 A Filer Information Provide the committee’s full name, telephone number, street address, city, state, zip code, and committee ID number. B Date, Report Number, Number of Pages CLEAR FORM Indicate the date the report is being filed; assign a unique number to each Form 497, such as 1, 2, 3, PR-1, PR-2, PR-3, etc.; and, indicate the number of pages included in the report. PRINT FORM
PRIMARY
Check if Loan
OTHER
%
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
Reason for Amendment:
FPPC Form 497 (Feb/2021) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov
Fair Political Practices Commission advice@fppc.ca.gov
Chapter 11.7
Campaign Manual 2 August 2023
382
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