Connecticut Citizens For Ballot Initiative
P.O. Box 684
South Windsor,
CT 06074-3747
Name: _____________________________________________________________________
Residential Address: ___________________________________________________________
City, State Zip: _______________________________________________________________
Best Phone Number:
________________________________
Cell:
________________________________
Work:
________________________________
Home:
________________________________
Best Email:
_________________________________________________________________
Alternate Email: __________________________________________________________
Over Age 18? (Y/N): ___________
Marital Status: _____________________
Employer:
_______________________________ Occupation/Position: _________________
Contribution Amount: $_____________ ($750 maximum per person, $30 maximum if under 18 years old)
___ Cash ___ Check ___ Money Order ___ Debit Card ___ Credit
Card
Card Type: ___________________ Name on Card:
__________________________________
Acct #:
__________________________________ Exp Date: ___________ Sec. Code:
_______
I understand that if I am under 18 years of age, the maximum annual contribution I am allowed to give is $30
I affirm that I am either a United States citizen or a foreign national with permanent resident status in the United States.
___ Yes ___ No Are you a lobbyist, lobbyist spouse, or lobbyist dependent?
___ Yes ___ No Do you, or a business with which you are associated, have a contract with the state valued at more than $5,000?
I understand that I have a legal obligation to pay and intend to pay from my own personal funds; payment is not made from the funds of a corporation, labor organization or any other entity. I understand that donations to the Connecticut Citizens For Ballot Initiative are not tax-deductible because Connecticut Citizens For Ballot Initiative is a State Political Action Committee (PAC).
Signature: _____________________________________________ Date: ________________
Any questions about contributing, contact our treasurer at (203) 846-9900
100% of our contributions go to making positive change in our state.