ZIMMER FOR SCHOOL BOARD 2013

ID# 1346463
CONTRIBUTION FORM

The following information is required by California State laws for all

contributions. We are prohibited from depositing any check without this
information.

Name: ________________________________________________
Street Address: ______________________________________
City/State/Zip Code: _________________________________
Occupation: __________________________________________
Employer: ____________________________________________
If Self-Employed, nature of business: ________________
If Political Action Committee, ID number: ____________
Amount of Contribution: $ ____________________________
This information is optional for reporting purposes:
Email: _________________ Business Phone: _________________

CREDIT CARD INFORMATION

*BOTH SECTIONS MUST BE COMPLETED FOR CREDIT CARD CONTRIBUTIONS. PLEASE PRINT CLEARLY.

Name on Card: ________________________________________

Address on Bill: ____________________________________
_____________________________________________________
Card Number: _________________________________________
V-Code: _____________________________________
Expiration Date: _____________________________________
Amount: $ ____________________________________________
Signature: ___________________________________________

Master Card ____

VISA ____
American Express____
Personal ___________ Business ___________

Discover____

Please make checks payable to :

STEVE ZIMMER FOR SCHOOL BOARD 2013

3700 Wilshire Blvd. Suite 1050-B

Los Angeles, CA 90010
Corporate and individual contributions are accepted ~ Contributions to this
committee are not considered charitable contributions for income tax purposes.

PAID FOR BY STEVE ZIMMER FOR SCHOOL BOARD 2013

3700 Wilshire Blvd. Suite 1050-B, Los Angeles, CA 90010