| Please fill out all of the following information. If you are unemployed, write "none" in the space for employer. |
| Name: |
| Address: |
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Zipcode: |
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Corporate contributions cannot be accepted. Contributions are not tax deductible.
Federal law prohibits contributions to the
campaign from corporations, labor organizations and national banks; from any person contributing another person's funds; from foreign nationals who lack permanent resident status; from federal government contractors. |
| Federal law requires political committees to report the name, mailing address, occupation, and employer for each individual whose contributions aggregate to $200 or more per calendar year. |