Naomi Bar-Lev for Congress

CONTRIBUTION FORM

 

 

This contribution was referred by: First name _______________ Last name________________________

[    ] Enclosed is my contribution by personal check (payable to Naomi for Congress) in the amount of:

 

[    ] $4,600 per couple (maximum primary donation) [ ] $2,300 per person (maximum primary donation)

[    ] $1,000 per person [ ] $500 per person [ ] $250 per person [ ] Other $_____________

[    ] To contribute by personal credit card, please complete the following:

Please circle one: Visa      MasterCard           American               Express

Name on Card _________________________________________ Amount ____________

Card Number ________________________________ Exp Date _________

My signature verifies that this contribution represents my personal funds and is not drawn on an account

maintained by an incorporated entity or other prohibited sources.

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Signature of Contributor

Please mail or fax this completed form (or address inquiries) to:

Naomi for Congress

415 Laurel Street PMB 526 San Diego, CA 92101

Fax: (619) 491-0178  Email: Naomi@naomiforcongress.com

ALL CONTRIBUTORS MUST COMPLETE THE FOLLOWING INFORMATION. WE ARE REQUIRED TO REPORT THE NAME,

ADDRESS, OCCUPATION AND EMPLOYER OF ALL CONTRIBUTORS*.

__________________________________________________ _________________________________________________________

Full Name Your Spouse’s Name & Signature (Required if Joint Contribution)

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Occupation Employer

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Spouse’s Occupation (Required if Joint Contribution) Spouse’s Employer (Required if Joint Contribution)

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Your Address

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City State Zip Code

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Work Phone Fax

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Home Phone Cell Phone

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E-Mail

Contributions are not deductible as charitable contributions for federal income tax purposes. * Federal Election Law requires us to report the

name, address, occupation, and employer for contributions aggregating in excess of $200 in an election cycle. The maximum an individual

may contribute is $2,300 for the primary election and an additional $2,300 for the general election. Couples may contribute $4,600 for the

primary and general elections, respectively. Federal PACs may contribute $5,000 for each election. Contributions from corporations, labor

unions, federal government contractors, national banks, and foreign nationals without permanent residency status are prohibited.

415 Laurel Street PMB 526 San Diego, CA 92101

Paid for by Naomi for Congress, I.D. # C00446781