Mitt Romney 2008 - Donorform

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. CONTRIBUTOR INFORMATION

Name: Prefix: _______ First: ____________________ Middle:_________ Last: ____________________________________ Nickname: ____________________ Spouse Name: ________________________ Home Phone: ________________________ Address:___________________________________________________________ Work Phone: ________________________ City:_________________________________ State:________ Zip:___________ Fax: _______________________________ Employer: _______________________________________

Cell Phone: _________________________

Occupation:________________________________________

Email:____________________________________________

Preferred Contact Person Information: ___________________________________________________________________ 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 and this contribution will not be reimbursed by another person. SIGNATURE:_______________________________________________________

JOINT CONTRIBUTOR (SPOUSE) INFORMATION

Name: Prefix: _______ First: ____________________ Middle:_________ Last: ____________________________________ Nickname: ______________________________ Employer: ______________________________________

Occupation ___________________________________________

If this contribution is intended to be a contribution from a couple, signature of spouse must be provided. SIGNATURE:_______________________________________________________

CREDIT CARD CONTRIBUTIONS

Credit Card: (circle one)

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By checking the box below, I certify that: (1) I am using my personal credit card; (2) I am a U.S. citizen or permanent resident; (3) My contribution will not be reimbursed by another person.
If you understand and comply with the statement above, please check this box.

Card Number:__________________________________________________________________________________________ Amount: $________________________________________ Expiration Date:______________________________________ Cardholder Name:__________________________________ Signature:____________________________________________ Contributions are not tax deductible as charitable contributions for federal income tax purposes. By law, the maximum amount an individual may contribute is $2,100 ($4,200 per couple) per election. Federal multicandidate PACs may contribute $5,000 per election. Contributions by corporations, foreign nationals (non green-card holders), labor unions and federal government contractors are prohibited. 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 ______________________

Mail to: PO Box 55899 Boston, Massachusetts 02205