DR. EMILY MURASE FOR DISTRICT 7 SUPERVISOR 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: ___________________________ If you are self-employed, Please list your line of work. please list the name of the entity that is on your paycheck. “Business Person” is not acceptable. Enter type of business instead. □ 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 estate 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 Mail this form to "Dr. Emily Murase for District 7 Supervisor 2020," P.O. Box 320218, San Francisco, CA 94132-0218. Paid for by Dr. Emily Murase for District 7 Supervisor 2020. Financial disclosures are available at sfethics.org.