You are on page 1of 1

!

!"#$%&'$("&)*%++,$*-.*/')$/"$%$!"#"$%&'()0"&$

!"#$$%&'#()%
*#)+,-.%/0'12%3$4.%5678%! *+,,)$-.-)/)0+,,)$-.-) 12")3456&("7)8)94.5"7):;)<)=%7""%)9->-;)>?@2&(A%'(;)3-B-) % % %%%%%"#$%!&'()*+,-!.*!/..'+0!*(!"12%%%!&'()*+,-%.*!3*).! %%%%%"12%%%!&/>!.*!/..'+0!*(!"#2$%%!&/>%.*!3*).
!

9!:;<%=,>',%91??#%@%%% %

"#$%%&45677*89:');<*=%#'%A36BC%5DEF3DBG%
!

[ ] Yes, I will be attending the Reception.

[ ] No, I am unable to attend

Enclosed is my contribution for the reception: o $5,000 o $2,500, o $1,000, o $500, o $250, o Other Name: Address: City: State: Zip: Telephone: (O) (H) E-Mail: Federal 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 $200 in an election cycle. Please complete the following information:! Occupation: Credit Card Contribution: Please charge my contribution of $ Card Number Signature:
[ ] This contribution is made on a personal or debit card for which I have the legal obligation to pay, and is not made on a corporate or business entity card. [ ] Please check to confirm the following statements are true: (1) I am a United States citizen or an individual lawfully admitted with permanent residence status (e.g., a green card holder); (2) This contribution is made from my own personal funds and is not made from the general treasury funds of a corporation, labor organization, or national bank; (3) I am not a federal government contractor; (4) I am at least 18 years old. !

Employer: to my credit card. [ ] Visa [ ] Mastercard [ ]AMEX Exp. Date

Please make checks payable to New Hampshire for Scott Brown Exploratory Committee Mail Address: P.O. Box 600 | RYE, NH 03870
To contribution online please visit ~ scottbrown.com/donate/ Please include the following Information: FUND21840
!

Contributions to the New Hampshire for Scott Brown Exploratory Committee are not tax deductible as charitable contributions for federal income tax purposes. By federal law, the maximum amount an individual may contribute is $2,600 per election (the primary and general elections are separate elections) or a total amount of $5,200 per election cycle. Political Action Committee (PACs) may contribute up to $10,000. A $10,000 PAC contribution will be allocated, as follows: $5,000 to the Primary Election account and $5,000 to the General Election account. Contributions from corporations, labor unions, foreign nationals and federal government contractors are prohibited.
Paid for by New Hampshire for Scott Brown Exploratory Committee - www.scottbrown.com

You might also like