Master of Ceremonies Hon.

David Paterson
Hon. Charles E. Schumer, Hon. Kirsten Gillibrand, Hon. Andrew Cuomo
Hon. Thomas DiNapoli, Hon. Sheldon Silver, Hon. Michael Bloomberg,
Hon. Christine Quinn, Hon. John Liu, Hon. Bill de Blasio
And Members of the NY Congressional Delegation
Special Performance by the Queen of Soul ARETHA FRANKLIN
Wednesday – August 11, 2010 6:00pm – 8:00pm
The Grand Ballroom of the Plaza Hotel – New York City
Yes! I want to join the leadership of the Rangel Birthday Gala Committee and have my name listed as a:
Host $5,000 Sponsor $2,500 Patron $1,000
Charlie’s Circle $500 Special Guest $200
---------------Please RSVP to Walter Swett at (212) 862-4990 or fax this form to (212) 862-4845---------------
NAME: ______________________________________________________________________
OCCUPATION: ___________________________ EMPLOYER: _______________________________
ADDRESS: ______________________________________________________________________
CITY: ____________________________ STATE: ______________ ZIP: _______________
PHONE: _________________ FAX: _____________ EMAIL: __________________________
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By signing below, I affirm that I am making this contribution with my own personal credit card and not with a
corporate or business credit card or one issued to another person. ____________________________________
Individual contributions of amounts up to $9,800 will be divided as follows between the National Leadership PAC and Rangel for Congress. Individual contributions up to
$4,800 will be attributed to Rangel for Congress. Amounts in excess of $4,800 (but not greater than $9,800) will be attributed entirely to the National Leadership PAC. (For
individual contributions attributed to Rangel for Congress, the first $2,400 is designated for the primary election, and the second $2,400 shall be treated as designated for the
general election, subject to 11 C.F.R. §110.1(b)(5)(ii)(B).) Federal multi-candidate committee contributions of amounts up to $15,000 will be divided as follows between the
National Leadership PAC and Rangel for Congress. Federal committee contributions up to $10,000 will be attributed to Rangel for Congress. Amounts in excess of $10,000
(but not greater than $15,000) will be attributed entirely to the National Leadership PAC. (For federal multi-candidate committee contributions attributed to Rangel for
Congress, the first $5,000 is designated for the primary election, and the second $5,000 shall be treated as designated for the general election, subject to 11 C.F.R. §110.2(b).)
Any contributor may designate his or her contribution for a particular participant. The allocation formula above may change if any contributor makes a contribution that,
when allocated, would exceed the amount that the contributor may lawfully give to any participant. Contributions and gifts to the Rangel Victory Fund are not tax deductible
for federal income tax purposes. Federal law requires us to use our best efforts to collect the name, address, occupation and employer of all donors.

Please return this form with your check to:

Rangel Victory Fund, P.O. Box 5577, Manhattanville Station, NY 1002
Paid for by Rangel Victory Fund, a joint fundraising committee authorized by the National Leadership PAC & Rangel for Congress.