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Type or print in ink. <br /> Late Contribution Report Amounts may be rounded to whole dollars. <br /> LATE CONTRIBUTION REPORT <br /> NAME OF FILER ,,,�. , Date of Date Stamp � � . � <br /> ��(A���'� �ir�S� �/�-- �\� l�1��j'1Uj 1 This Filing • - � • <br /> AREA CODE/PHONE NUMBER I.D.NUMBER�iiapp�icab�e - For Official Use Only <br /> �� �. �(���� l� I Report No. <br /> STREET ADDRESS <br /> ! t❑oRe ortNont �r. r � `<; ��ur� <br /> p <br /> CITY STATE ZIP CODE (explain below) . <br /> f�� �, \� � �� �, No. of Pages_� <br /> VY'�,�p � <br /> Late Contribution(s) Rece ved <br /> IF AN INDIVIDUAL, <br /> DATE FULL NAME,STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR AMOUNT <br /> RECEIVED (IFCOMMITfEE,ALSOENTERI.D.NUMBER) CODE * ENTEROCCUPATIONANDEMPLOYER RECEIVED <br /> (IF SELF-EMPLOYED,ENTER NAME OF BUSINESS) <br /> e�. n t�a �' ��� �-, ��S }�SsOC. o �No <br /> � �� o`� nc +,��� y � .�oM �` �y� ��J <br /> I / �`� � ❑ OTH 7 � �(1 C.�(../c-� <br /> (� �� � � � � ❑ PTY <br /> r �`� � ��D� ❑ SCC ❑ Check if Loan <br /> �fL`i� '�I+�� � �9(�� IU� I�- .�.'IND �`V'���f /U�� 1��. <br /> /b/�� � � ��(� �� �' � o�H o��}C� �hCY �^ -��� �C?G'�,a� <br /> �� �l�D �0�� �C � �'!�d�S� ❑ Pnr ��U�. �S�`��.��e�T" � <br /> r r ❑ scc <br /> ❑ Check if Loan <br /> ❑ IND <br /> ❑ COM <br /> ❑ OTH <br /> ❑ PTY <br /> ❑ SCC ❑ Check if Loan <br /> 'Contributor Codes <br /> IND—Individuat PTY—Political Party <br /> COM—Recipient Committee(other than PN or SCC) SCC—Small Contributor Committee <br /> OTH—Other(e.g.,business entity) <br /> Reason for Amendment: <br /> FPPC Fortn 497(Januaryl05) <br /> FPPC Toll-Free Helpline: 866/ASK-FPPC(866/275-3772) <br />