Please print this page, provide the information requested, and mail it along with
your personal check to the following address:
Bob Moss for City Council
4010 Orme Street
Palo Alto, CA 94306
Please make your check payable to:
Bob Moss for City Council
The maximum an individual may contribute is $300. Contributions to Bob Moss for City Council
are for use in connection with the Palo Alto City Council election and are subject to the
prohibitions and limitations of the FPPC. All contributions must be made from personal funds
and may not be reimbursed by any other person.
State law requires us to use our best efforts to collect and report the name, mailing address,
occupation and name of employer of individuals whose contributions exceed $100 in a calendar year.
Please print this form and provide the following required information.Name:
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Employer:¨Check here if self-employed ______________________________________
Contributor Signature: _____________________________________
The following information is optional, but we would appreciate having it.
E-mail Address: _____________________________________
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Thank you for your contribution to Bob Moss for City Council!
Contributions to Bob Moss for City Council are not tax deductible for federal income tax purposes.
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