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Ralph de la Torre & Edwards Wildman PAC

Cordially invite you to a Reception In honor of

United States Senator Scott Brown

Friday, November 18th, 2011 Edwards Wildman & Palmer LLP 111 Huntington Avenue, 20th Floor Boston, Massachusetts 5:00pm- 5:30pm $2,500 Host Committee Reception 5:30-7:00pm $500 General Reception
$2,500 contribution includes entrance to Brown Campaign quarterly Host Receptions and Photo Opportunity with Senator Brown

______________________________________________________ RSVP to Jason Zanetti at

An individual can contribute up to $5,000 to the Brown for US Senate Committee between January 20, 2010 and Election Day 2012 and up to an additional $30,800 to the Brown Victory Committee per person, per year. The maximum, personal contribution that can be received in a single check to the Brown Victory Committee is $35,800. Please call (781) 444-0200 if you have any questions about your contribution limits.

this senate seat belongs to no one person and no political party as I have said before, and you said loud and clear today, it is the peoples seat.- January 19, 2010

Paid for by Brown for US Senate Committee Inc.

SCOTT BROWN FOR US SENATE COMMITTEE DONOR FORM I will contribute the maximum individual amount of $5,000 for the 2012 election cycle by filling out the information below **(A single $5,000 check is split into $2,500 to the Primary Election account and $2,500 for the General Election account once deposited) I will contribute $_________ for the 2012 election cycle by filling out the information below. Political Action Committees (PACs) may contribute $10,000 for the 2012 election cycle **(A single $10,000 PAC check is split into $5,000 to the Primary Election account and $5,000 for the General Election account once deposited) NOTE: If an individual would like to contribute above $5,000 (or couple above $10,000) to the Brown campaign please refer to the attached Brown Victory Committee donation form.
Enclosed is my contribution of 00 (couple only) 5,000 00 Other________

Please complete the following: Name:________________________________________________Signature_____________________________________________ Address:__________________________________________________________________________________________________ City: _______________________________________ State:____________________Zip:__________________________________ Phone: Office Cell Home______________________________E-mail:____________________________________________

Occupation: (required)_____________________________________ Employer: (required)____________________________________

Joint Contributor (spouse) Information: (Joint Donations up to $10,000 per couple can be accepted on this form)

Name:__________________________________________________Signature___________________________________________ Phone: Office Cell Home______________________________E-mail:______________________________________________

Occupation: (required)_____________________________________ Employer:(required)_____________________________________

For a contribution from a joint account to be attributed equally to two individuals, both must sign this form, indicating agreement with the above statement.

Credit Card Contribution: Please charge my contribution of $________________ to my credit card. [ ] Visa [ ] Discover [ ] MasterCard [ ] AMEX Card Number_________________________________Exp.Date_________________________CVV________________________ Billing Address (if different than above):____________________________________________________________________________ Signature(s):______________________________________________________________________________________________
Please make checks payable to Scott Brown for US Senate Committee Mail to Brown for US Senate, 200 Reservoir Street, Suite 101, Needham, MA 02494 Or please scan and email this form to:

Fundraiser ID: Ralph de la Torre FUND23270

Event Code: M3095

[ ] Please check to confirm the following statements are true: (1) I am a United States citizen or an individual lawfully admitted with permanent residence status (e.g., a green card holder); (2) This contribution is made from my own personal funds and is not made from the general treasury funds of a corporation, labor organization, or national bank; (3) If I have paid by credit card, I also certify that this contribution is made on a personal credit or debit card for which I have the legal obligation to pay, and is not made on a corporate or business entity card; (4) I am not a federal government contractor; (5) I am at least 18 years old. Contributions to the Scott Brown for U.S. Senate Committee are not tax deductible as charitable contributions for federal income tax purposes. By federal law, the maximum amount an individual may contribute is $2,500 per election (the primary and general elections are separate elections) or a total amount of $5,000 per election cycle ($10,000 per couple). Political Action Committee (PACs) may contribute up to $5,000 per election ($10,000 max). Contributions from corporations, labor unions, foreign nationals and federal government contractors are prohibited.

Paid for by Scott Brown for U.S. Senate Committee, Inc. Paid for by the Brown Victory Committee