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Type or print in ink. <br /> Late Contribution Report Amo�ntsmayberoundedtowholedollars. <br /> LATE CONTRIBUTION REPORT <br /> NnMe oF Fi�eR . �} Date of DateStamp <br /> �.1C�,��� -�� � �� ! � � 2�� ' ' <br /> � � oC This Filing <br /> AREA CODElPHONE NUMBER I.D.NUMBER(ifapplicaW' FOY OfP1C1 Use Only <br /> ���� �/ (��..c..._�� t��d� � � f-- Report No. ��"'(��„ <br /> � <br /> STREET ADDRESS � `�` _� a <br /> � �� �Amendment <br /> to Report No. <br /> CITY !^� STATE ZIPCODE (explain below) <br /> �✓'��-��� � ���If,...,� No.of Pages <br /> r�._ �,n..� <br /> Late Contribution(s) Received <br /> IF AN INDIVIDIiAL, <br /> DATE FULL NAME,STREET ADDRESS ANO ZIP CODE OF CONTRIBUTOR CONTRIBUTOR ENTER OCCUFATION AND EMPLOYER AMOUNT <br /> RECEIVED �IF COMMiTfEE.ALSO ENTER I.D.NUMBER) CODE i` (�p SELP-EMPLOYEO,ENTER NAME OF BUSINESS) RECENED <br /> IND <br /> (k,�u,t��S �.�.t coM ����t.5��t�� ��,� e� ,� i ��. `=' <br /> 1��I� ��`✓'�� �� ��+- "�" � � PTY `� C'�V1 i1 �'.:�C����+It � <br /> `�,���;c,�-,�, C.�-� , �t=� �u�tx:>> —�3 w Z ,_,.,� ;� � <br /> j� � SCC Check if Loan <br /> � IND <br /> � COM <br /> � OTH <br /> � PTY <br /> � SCC �Check if Loan <br /> � IND <br /> � COM <br /> � OTH <br /> � PTY <br /> � SCC �Check if Loan <br /> 'Contributor Codes <br /> IND—Individual PlY—Political Party <br /> COM—Recipient Committee(other than PTY or SCC) SCC—Smali Contributor Committee <br /> OTH—Other <br /> Reason fo�Amendment: <br /> FPPG Form 497 (Jan/03) <br /> FPPC Tol1-Free Helpline: 866fASK-FPPC <br /> 866l275-3772 <br />