You are on page 1of 1


Name: Prefix: ______ First: ______________________ Middle Initial: _____ Last: _________________________________
Address: ___________________________________________________________________________________________
City: ______________________________________________ State: _________ Zip: ___________________
Phone: ____________________ Fax: ____________________ Email: __________________________________________
Employer: ____________________________(Required) Occupation: ___________________________________(Required)
This contribution is made by check or credit card from my personal funds and is not drawn on an account maintained by an incorporated entity. I am a
U.S. citizen or permanent resident and this contribution will not be reimbursed by another person.


By law, the maximum amount an individual may contribute is $2,300 ($4,600 per couple) per election.
Federal multi-candidate PACs may contribute $5,000 per election.
Name: Prefix: ______ First: ____________________ Middle Initial: _____ Last: _________________________________
Phone: ____________________ Fax: ____________________ Email: __________________________________________
Employer: ____________________________(Required) Occupation: ___________________________________(Required)
In order for a contribution from a joint account to be attributed equally to two individuals, both individuals must sign this form, as well as any check.


Please make checks payable to: Romney for President, Inc.

Credit Card: (circle one) VISA MasterCard American Express Discover
Card Number: _____________________________________ Amount: $_________________ Expiration Date: ___________
Cardholder Name: _______________________________________________________
Signature: _____________________________________________________________
If you are paying by credit card, you may fax this form back to (866) 891-3307, scan and email it to,
or mail it to the address below.

Mail to: Romney for President, Inc.

P.O. Box 55899, Boston, Massachusetts 02205
Source Code: ___________ Fundraiser ID: ________________
If you do not know the Source Code or Fundraiser ID, please fill in the name of the person that asked for this donation and the method
(letter, phone call, etc.) or event (name, location, and date) by which it was solicited.
Fundraiser Name: ______________________ Method: ____________ Location: ___________________ Date: ___________
Contributions are not tax deductible as charitable contributions for federal income tax purposes. Federal law requires us to obtain and report the
name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 per election cycle.
Contributions by corporations, foreign nationals (non green-card holders), labor unions and federal government contractors are prohibited.

Paid for by Romney for President, Inc.