$2400

$1000

$500

$250

$75

$50

$25

Other: $

First Name

Middle In.

Last Name

Address

City

State

ZIP

Email

Phone

• I confirm that the following statements are true and accurate: - I am not a foreign national who lacks permanent residence in the United States.
• I am not a Federal government contractor.
• This contribution is made from my own funds, and not those of another.
• This contribution is not made from the funds of a corporation or labor organization.
• This contribution is made on a personal credit card or debit card for which I have the legal obligation to pay, and is not made either on a corporate or business entity card or on the card of another person.
• I am at least eighteen years old.
  
  Federal law requires us to use our best efforts to collect and report the name, address, occupation and name of employer of individuals whose contributions exceed $200 per election cycle. We may accept contributions from an individual totaling up to $2,400.00 per election.