Mitt Romney 2008 - Contribution Form

CONTRIBUTOR INFORMATION Name: Prefix: ______ First: ______________________ Middle Initial: _____ Last: _________________________________ Address: ___________________________________________________________________________________________ City: ______________________________________________ State: _________ Zip: ___________________ Phone: ____________________ Fax: ____________________ Email: __________________________________________ Employer: ____________________________(Required) Occupation: ___________________________________(Required) This contribution is made by check or credit card from my personal funds and is not drawn on an account maintained by an incorporated entity. I am a U.S. citizen or permanent resident and this contribution will not be reimbursed by another person. SIGNATURE:_______________________________________________________

By law, the maximum amount an individual may contribute is $2,300 ($4,600 per couple) per election. Federal multi-candidate PACs may contribute $5,000 per election. JOINT CONTRIBUTOR (SPOUSE) INFORMATION Name: Prefix: ______ First: ____________________ Middle Initial: _____ Last: _________________________________ Phone: ____________________ Fax: ____________________ Email: __________________________________________ Employer: ____________________________(Required) Occupation: ___________________________________(Required) In order for a contribution from a joint account to be attributed equally to two individuals, both individuals must sign this form, as well as any check. SIGNATURE:_______________________________________________________

Please make checks payable to: Romney for President, Inc. CREDIT CARD CONTRIBUTIONS Credit Card: (circle one)

VISA

MasterCard

American Express

Discover

Card Number: _____________________________________ Amount: $_________________ Expiration Date: ___________ Cardholder Name: _______________________________________________________ Signature: _____________________________________________________________ If you are paying by credit card, you may fax this form back to (866) 891-3307, scan and email it to [email protected], or mail it to the address below.

Mail to: Romney for President, Inc. P.O. Box 55899, Boston, Massachusetts 02205 Source Code: ___________ Fundraiser ID: ________________ If you do not know the Source Code or Fundraiser ID, please fill in the name of the person that asked for this donation and the method (letter, phone call, etc.) or event (name, location, and date) by which it was solicited. Fundraiser Name: ______________________ Method: ____________ Location: ___________________ Date: ___________ Contributions are not tax deductible as charitable contributions for federal income tax purposes. Federal law requires us to obtain and report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 per election cycle. Contributions by corporations, foreign nationals (non green-card holders), labor unions and federal government contractors are prohibited. Paid for by Romney for President, Inc. www.mittromney.com