DR. EMILY MURASE FOR DISTRICT 7 SUPERVISOR Paid for by Dr. Emily Murase for District 7 Supervisor 2020 Financial disclosures are available at sfethics.org. Amount of Contribution: $_________ Contributions are not tax - deductible. Individuals and PACs may contribute up to $500. Spouses may each contribute the maximum from a joint account as long as they affirm in writing/email that it is a joint credit card or both sign the check. We may not deposit your check or credit card payment without your name, street address, occupation, and employer, and may not accept $100 or more in cash or cashier’s check. Form of payment : ☐ Check : please make check payable to “Dr. Emily Murase for D7 Supervisor 2020.” ☐ Credit Card: please go to www.emilymurase.com ☐ Cash : may not exceed $99.99 ( including money orders, cashier/travelers’ checks). Full Name (please print): ___________ _____________________________________________ Residential Street Address (no P.O boxes): ________________________________________ City/State/Zip Code: ________________________________________ Preferred Telephone & Email: ______ _ ____________________________________________ Employer: __________________________ Occupation: ___________________________ □ Please check to attest. By making a contribution, I attest under penalty of perjury that my contribution is not made by a: (1) corporation, LLC, or LLP; (2) registered San Francisco lobbyist; (3) foreign national (except for green card holders); (4) 10%+ owner, director, C - level officer, or named sub - contractor of an entity currently seeking a City contract subject to Board of Supervisors approval or which received such a contract in the previous 12 months; (5) director, officer, or owner with $5+ million interest in a real estat e project pending before a City Board or Commission or which has been approved by a City Board or Commission in the previous 12 months. I also attest that my contribution has not been reimbursed by another person. X_______________________________________ __________________________________________________________ Signature Date If you are self - employed, please list the name of the entity that is on your paycheck. Please list your line of work. “Business Person” is not acceptable. Enter type of business instead. Mail this form to "Dr. Emily Murase for District 7 Supervisor 2020," P.O. Box 320218, San Francisco, CA 94132 - 0218.