1. Contributor Information:
               Name         
               Address 1  
               Address 2  
               City            
               State          
               Zip             
               Phone Number       
               Email Address        

     2. Contribution:
               Amount of Donation

     3. Declarations:

     The contribution listed in item 3 was freely and voluntarily given by me (the committee) from my personal (the committee’s) property. I have not directly or indirectly been compensated or reimbursed for the contribution listed in item 3 (the committee has not, directly or indirectly been compensated for the contribution listed in item 3) by persons other than those from whom contributor statements have been received and of whom disclosure has or will be made.

                        I Agree I Disagree