497 Contribution Report Amounts may be rounded to whole dollars. Report No. _ _2_ ____ 0Amendment to Report No. ___ _ __..,, =-:---------------------,S"'~"' ATE=-----oZio-cPo-C=cO"'O:::------1 E (explain below) CA EmeryVille 94608 1 1 __ No.ofPages ________ 1. Contribution(s) Received DATE RECEN ED FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR OF COMMm£E, AlSO ENTER I 0 . NU I.IBER) Louise Engel 10/21/16 Emeryville, CA 94608 CONTRIBUTOR CODE* 12!J)4No D COM D OTH D PlY IF AN INDIVIDUAL, ENTER OCCUPATION AND EMPLOYER Self Employed. MP Dreams, Inc. 0 0 0 0 0 $2,300.00 XJ)fheck if Loan 0 D sec D D D D D AMOUNT RECEIVED (lF SElF.tMPL.,'IED, ENlER NAME OF BUSINESS) % Provide interest rate INO COM OTH 0 Checil if Loan PlY sec '!. Provide interest rate IND COM OTH 0 Check if Loan PlY sec ·~ Provide intersst rate "'*Contributor Codes Reason for Amendment:--- - - - -- - - - - - - -- -- - -- - - - - - ---- - - - - IND COMOTH PTY SCC - Individual Recipient Committee (other than PTY or SCC) 0\har (e.g. , biJsiness entity) Po ll ~cal Party Small Conlribulor Committee FPPC Forni 497 (lul/2016) FPPC Ad\lice: [email protected] (866/275-JnZl www.fppc.ca.gov
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