Please Join

Bill Samuels  Vin Roberti  Anne Hess & Craig Kaplan Dennis Mehiel  George Tsunis Robin & Bill Hubbard  Morris & Barbara Pearl
Committee in Formation

For a reception to support 2012 Candidate for Brooklyn’s 10th Congressional District

Assemblyman Hakeem Jeffries
Wednesday, March 7th 6:30pm ~ 8:30pm Hosted by Bill & Marie Samuels 18 E. 18th Street (between 5th Ave & Broadway)

Benefactor  Sponsor  Friend  Supporter

Suggested Contribution Levels

$2,500  $1,000  $500  $250

By federal law, the maximum contribution is $2,500 per individual or $5,000 per couple.

To make a contribution, or for more information, please go to www.JeffriesforCongress.com or complete the attached form.

Please RSVP by March 5th to Jacquisam77@gmail.com, or call 347-770-0010 for more information.
Paid for by Jeffries for Congress

JEFFRIES FOR CONGRESS CONTRIBUTION FORM
Contribution Contribution Amount: $ Check - Please make checks payable to: Jeffries for Congress
or

Cash - We can only accept up to $100 in cash contributions
or

Credit Card (check one) Card Number: Cardholder Name:

American Express

Mastercard

Visa

Expiration Date:

By law, the maximum amount an individual may contribute is $2,500 ($5,000 per couple) per election cycle. (The primary and general are separate elections.) Federal multi-candidate PACs may contribute $5,000 per election. Federal law requires us to obtain and report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 per election cycle. Contributions by corporations, foreign national, labor unions, federal government contractors and minors under the age of 18 are prohibited.

Contributor Information First Name: Address: City: Home Phone: Email: Employer: (required) Work Phone: Other Phone: Occupation: (required) State: Zip: Fax (if applicable): Last Name:

I am at least 18 years of age. This contribution is made from my personal funds and not from those of a corporation or labor organization. I am not a federal government contractor. I am a U.S. citizen or permanent resident and this contribution will not be reimbursed by another person

Signature: Joint Contributor Information (if applicable) First Name: Address: City: Home Phone: Email: Employer: (required) Work Phone: Other Phone: Occupation: (required) State: Zip: Fax (if applicable): Last Name:

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

To contribute go to www.JeffriesforCongress.com or mail your contribution along with this form to:

Lauren Bierman,The Advance Group, 39 Broadway Suite 1540, New York, NY 10006
Contributions are not tax deductible as charitable contributions for federal income tax purposes.

Paid for by Jeffries for Congress

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