Please join

Taxpayers for DiNapoli
For Cocktails in honor of TOM!
Wednesday April 11th, 2012 ◊ 6:00pm to 8:00pm
The Woodlands ◊ 1 South Woods Rd, Woodbury, NY
Entry Level_____$100 M anager_____$250 Vice-President_____$500
President_____$1,000

Philanthropist_____$2,500

_______# attendees
Names of Attendees________________________________________________________
I can’t attend but would like to support Tom with a contribution of $___________

To RSVP or for more info e-mail: Matthew@dinapoli2014 or call 518-813-5729.
Please charge $__________________ to my:

___ Visa

___ MasterCard

___ American Express

Account#______________________________________________________Exp.__________
Signature_______________________________________________________________
Name on card_______________________________________________________________
Contributor Name_______________________________________________________________
PAC, Part., or LLC Name(if applicable)__________________________________________________
Address__________________________________________________________________
City, State, Zip________________________________________________________________
Occupation__________________________________Employer__________________________
Phone______________________________________Fax____________________________
E m a i l_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 


Please make checks payable to “DiNapoli 2014” and mail to:
DiNapoli 2014
c/o Peggy May • PO Box 1776 • Mineola, NY 11501
or you may fax this form to (516) 873-9524
CONTRIBUTION DISCLAIMER:
Contributor’s Confirmation – DiNapoli 2014 does not accept contributions from: (1) any person employed by the Office of State Comptroller; or (2) any
person or entity who responds to a Request for Proposals (“RFP”) for legal business on behalf of the New York State Common Retirement Fund (the
“Fund”) (this restriction applies from the date the RFP is issued until the contractor is selected, and continues for the person or entity selected for such
contract with the Fund through the ninetieth day after such contract goes into effect). I hereby confirm that this contribution was made from the
contributor’s own funds, is not being reimbursed in any manner, and is not in either of the two prohibited categories (1) and (2) listed above.
Signature Required__________________________________

Print Name______________________________________

Contributions to DiNapoli 2014 are not deductible for federal income tax purposes. The maximum permissible contribution is $60,800. Partnerships that
make contributions exceeding $2,500 will be required to specifically identify the partners responsible for the contribution, and that amount will be
counted against each partner’s individual contribution limit. Total contributions from a corporation may not exceed $5,000 per calendar year to all New
York state and local political committees. Corporations, other entities and individuals are strictly prohibited from reimbursing another person or entity for
making a contribution. All contributors must be US citizens or permanent resident aliens (green card holder). Pursuant to SEC Rule 206(4)-5,
contributions by investment advisors and covered associates are regulated; the Rule should be consulted.
Paid for by DiNapoli 2014.

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