G.i.v.e. Contribution Form

(Grassroot Investors for Victory & Excellence) NAME: ____________________________________________________________ ADDRESS: __________________________________________________________ CITY/STATE/ZIP: ____________________________________________________ PHONE NUMBER: ____________________________________________________ E-MAIL ADDRESS: ____________________________________________________ EMPLOYER: ________________________________________________________ OCCUPATION: ______________________________________________________ Please Make Checks Payable to: ARIZONA DEMOCRATIC PARTY

M ONTHLY CONTRIBUTION AMOUNT:

$20 G.I.V.E. Club

(By checking this box I authorize the Arizona Democratic Party to debit my credit card in the amount indicated above once per month. This authority will continue unless the Arizona Democratic Party receives a written request from me to terminate the debits.)

CREDIT CARD INFORMATION: PLEASE CIRCLE ONE: Visa / Mastercard / American Express CARD #: ______________________________________

EXP DATE:_____/______

SIGNATURE ____________________________________

DATE: _______________

Contributions are not tax deductible for federal income tax purposes. Paid for by the Arizona Democratic Party, Rick McGuire, Treasurer Your contribution will be used in connection with federal elections and is subject to the limitations and prohibitions of the Federal Election Campaign Act. Federal law requires us to use our best efforts to collect and report the names, mailing address, occupation and name of employer of the individuals whose contributions exceed $200 per calendar year. Not authorized by any candidate or candidate’s committee. www.azdem.org

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