Donate - Monthly Contribution

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Billing Name (As it appears on your credit card)

Title:
First name:
Last name:

Billing Address

Address 1:
Address 2:
City / State:
Postal Code/Zip:
Phone Number:

Select an Amount to Contribute

$25

$100

$1000

$5000

	I would like to make this amount a monthly contribution
	# of Months

Payment Method

Credit Card Number:
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Expiration Date:

Enter Employment Information

Federal Election Law requires political committees to report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 per election cycle

Employer:
Occupation:	(enter “none” if not employed)

Select Contribute Fund

Please select the fund you would like your contribution to be allocated to.

Confirm Your Eligibility

By checking this box, I confirm that the following statements are true and accurate:

	I am a citizen or permanent resident in the United States.
	The funds I am contributing are my own personal funds and not those of another person.
	My contribution is not from the general treasury funds of a corporation, organization or national bank.
	I am not a federal contractor.
	I am not a foreign national who lacks permanent resident status in the United States.
	I affirm that I am making this contribution via my personal credit or debit card for which I have a legal obligation to pay, and not through a corporate or business entity card or the card of another person.

Confirmation of Donation

Employer:

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PAC: The maximum contribution for PAC is $5,000 per calendar year.

Individual: The maximum contribution for Individual is $5,000 per calendar year.

PAC FUNDS WILL BE USED FOR POLITICAL PURPOSES. CONTRIBUTIONS CANNOT BE DEDUCTED AS A CHARITABLE CONTRIBUTION FOR FEDERAL TAX PURPOSES.

Donate – Monthly Contribution

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