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Please print, fill out and mail back with your contribution.
Or click here to view and print in PDF format. Thank you.
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$10,000
max. amount per couple (primary & general)
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$5,000
max. amount per individual (primary & general)
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$2,500
$1,500
$1,000
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$500
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$100
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Other
amount please specify |
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PERSONAL CHECKS PAYABLE TO “WILDES FOR CONGRESS” PLEASE
SIGN BELOW, ENCLOSE THIS LETTER, AND MAIL TO: WILDES FOR CONGRESS,
P.O. BOX 5903, ENGLEWOOD, NJ 07631-5903
FEDERAL
LAW REQUIRES OUR CAMPAIGN TO USE OUR BEST EFFORTS TO COLLECT &
REPORT THE NAME, MAILING ADDRESS, OCCUPATION,AND EMPLOYER OF INDIVIDUALS
WHOSE CONTRIBUTIONS EXCEED $200 PER ELECTION CYCLE.
PLEASE
HELP BY SUPPLYING THE FOLLOWING:
Name: |
__________________________________________________________ |
Address: |
__________________________________________________________ |
Telephone: |
__________________________________________________________ |
Email: |
__________________________________________________________ |
Fax: |
__________________________________________________________ |
Occupation: |
__________________________________________________________ |
Employer: |
__________________________________________________________ |
PLEASE
AFFIRM YOUR KNOWLEDGE AND COMPLIANCE WITH THE FOLLOWING BY SIGNING
BELOW
1. Contributions to “Wildes for Congress” are not deductible
for federal income tax purposes.
2. Contribution to “Wildes for Congress” is limited to $2,500
per individual per election period (primary/general). Contributions
to the primary and general
election funds may be made at the same time, in one contribution.
Therefore, an individual may contribute a maximum of $5,000 per election
cycle.
3. If the contribution is drawn from a joint account, the campaign
can accept a single contribution of up to $10,000 per cycle, attributed
to both individuals,
either with both contributors’ signatures on the check or an
accompanying letter. Please fill out above information for both individuals.
4. Contributions to “Wildes for Congress” are intended for
use in connection with the U.S. Congress Election of 2014, and are
subject to the prohibitions and
limitations of the Federal Election Campaign Act.
5. Contributions from corporations, national banks, federal contractors,
labor organizations, professional organizations, and foreign nationals
who are not permanent
residents of the United States are prohibited. I certify the donation
does not come from the prohibited entities listed.
6. All contributions must be made from personal funds and may not
be reimbursed or paid by any other person.
7. I permit “Wildes for Congress” to transfer my contribution
in any manner in compliance with Federal and/or appropriate State
Election laws.
Signature _____________________________________________
Date __________________________
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