A F UNDRAISING R ECEPTION FOR

T HE M ANCHESTER D EMOCRATIC
T OWN C OMMITTEE

W ITH S PECIAL
H ONORED G UEST

G OVERNOR
D ANNEL P. M ALLOY
F RIDAY , F EBRUARY 18 TH
M ANCHESTER C OUNTRY C LUB
305 S OUTH M AIN S TREET

5:00-7:00 PM

$75 PER P ERSON

I NFO / RSVP: M ICHAEL S TEBE , (860) 268 8893
MASTEBE @ GMAIL . COM / MANCHESTERDTC @ AOL . COM

Paid for by the Manchester Democratic Town Committee. Thomas Robinson, Treasurer
 A RECEPTION FOR THE MANCHESTER DEMOCRATIC TOWN COMMITTEE
WITH SPECIAL HONORED GUEST – GOVERNOR DANNEL P. MALLOY
FEBRUARY 18, 2011

_____ YES I will attend and purchasing _____ tickets at $75 per person.

_____ I will not be able to attend, but would like to support the Manchester Democratic Town Committee with a contri-
bution of $________.

Manchester Democratic Town Committee – Individual Contributions

Please Complete All Information Legibly and mail with your personal check to:

Manchester Democratic Town Committee

c/o Thomas Robinson, Treasurer, 31 Tonica Spring Trail, Manchester, CT 06040

Name_________________________________________________________________

Home Address__________________________________________________________

City___________________________________ State______ Zipcode______________

Employer______________________________________________________________

Occupation_____________________________________________________________

Phone Number__________________________________________________________

Email_________________________________________________________________

Amount of Contribution: $__________________

(Please note that the maximum annual contribution allowed by law is $1,000 per individual.)

Are you a lobbyist? Y/N Spouse of a lobbyist Y/N Dependent of a lobbyist Y / N

Do you individually have a contract with the Town of Manchester which is valued at more than $5,000? Y/N

Does a business that you are associated with have a contract with the Town of Manchester valued at more than $5,000? Y / N

Do you individually have a contract with the State of Connecticut which is valued at more than $5,000? Y/N

Are you a director, officer, owner, limited or general partner or a holder of 5% or more of stock for a business which has a contract
with the State of Connecticut which is valued at more than $5,000? Y / N

In making an individual contribution to the Manchester Democratic Town Committee, you confirm that the following statements are
true and accurate:

• I am either a United States citizen or a foreign national with permanent resident status in the United States.
• This contribution is paid from my own personal funds; payment is not made from the funds of a corporation, labor organization or
any other entity.
• I am at least 16 years old.

Signature____________________________ Print Name__________________________ Date___________________

Paid for by the Manchester Democratic Town Committee. Thomas Robinson, Treasurer
Contributions are not deductible for Federal Income Tax Purposes.