Name *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Campaign Finance Affirmation *

I affirm that I am a citizen or lawful permanent resident (green card holder) of the United States. I understand that State law requires that a contribution be in my name and be from my own funds. I hereby affirm that this contribution is being made from my personal funds, is not being reimbursed in any manner, and is not being made as a loan. In addition, in the case of a credit card contribution, I also hereby affirm that this contribution is being made from my personal credit card account, billed to and paid by me for my personal use, and has no corporate or business affiliation.

FOR MONTGOMERY COUNTY RESIDENTS ONLY *

(ONLY CHECK IF YOU ARE A MONTGOMERY COUNTY RESIDENT) I affirm that I AM a Montgomery County resident.