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1. Contact Information

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Middle

Last Name *

Address *

City *	State *	Zip Code *
Country I confirm that I am a U.S. citizen living abroad. *
Email Address *	Phone Number *

2. Employment

Note: Federal law requires we report the name, mailing address, occupation, and name of employer for contributions of more than $200.00 per election cycle.

Employer *

Occupation *

If you are not employed, enter “none” in the occupation and employer boxes.

Individuals may contribute up to $2,300.00. Couples may contribute up to $4,600.00. Contributions are not tax deductible. Corporate contributions are prohibited.

3.Referral/Event Information (optional)

Email Address of Referrer	Event Code
Please leave these fields blank if you were not referred and have no event code.

4. Confirm Your Eligibility

Federal law requires all online contributors to confirm that the following statements are true and accurate. If you cannot confirm each statement, you are not eligible to contribute to the Campaign.

1. This contribution is made on a personal credit or debit card for which I have the legal obligation to pay, and is made neither on a corporate or business entity card nor on the card of another.

2. I am a United States citizen or a lawfully-admitted permanent resident.

3. I am making this contribution with my own personal funds, and I will not be reimbursed by anyone for this contribution.

4. I am not a federal government contractor.

5. I am at least 18 years of age.

* By checking this box, I confirm that each of the above statements is true and accurate.

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