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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.

Name: Prefix: _______ First: ____________________ Middle:_________ Last: ____________________________________
Nickname: ____________________ Spouse Name: ________________________ Home Phone: ________________________
Address:___________________________________________________________ Work Phone: ________________________
City:_________________________________ State:________ Zip:___________ Fax: _______________________________
Employer: _______________________________________ Cell Phone: _________________________
Occupation:________________________________________ Email:____________________________________________
Preferred Contact Person Information: ___________________________________________________________________
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 and this contribution will not be reimbursed by another person.


Name: Prefix: _______ First: ____________________ Middle:_________ Last: ____________________________________
Nickname: ______________________________
Employer: ______________________________________ Occupation ___________________________________________
If this contribution is intended to be a contribution from a couple, signature of spouse must be provided.


Credit Card: (circle one) VISA MasterCard American Express Discover

By checking the box below, I certify that: (1) I am using my personal credit card; (2) I am a U.S. citizen or permanent resident; (3) My contribution will not be
reimbursed by another person. 

If you understand and comply with the statement above, please check this box.

Card Number:__________________________________________________________________________________________

Amount: $________________________________________ Expiration Date:______________________________________

Cardholder Name:__________________________________ Signature:____________________________________________

Contributions are not tax deductible as charitable contributions for federal income tax purposes. By law, the maximum amount an individual may
contribute is $2,100 ($4,200 per couple) per election. Federal multicandidate PACs may contribute $5,000 per election. Contributions by
corporations, foreign nationals (non green-card holders), labor unions and federal government contractors are prohibited.

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 ______________________
Mail to: PO Box 55899 Boston, Massachusetts 02205