Sign Up Form

You are cordially invited to a luncheon in support of

New York State Governor David A. Paterson

Monday, November 23, 2009 • 12:00pm to 1:30pm • AVANT • 200 Delaware Avenue • Buffalo, New York

Join the Event Committee ➠ YES, I would like to join the Event Committee as a: ❍ Chair: Pledge to contribute/raise $5,000

❍ Vice Chair: Pledge to contribute/raise $2,500

Name to be listed: _________________________________________________________ -OR- ❍ Please do not list my name.

Make a Contribution ❍ I/we will attend the luncheon and have enclosed my/our contribution of: ❍ $5,000 ❍ $2,500 ❍ $1,000 ❍ $500 ❍ Other: $__________ (minimum $500 per person) Name(s) of attendee(s): ________________________________________________________________________________ ❍ I/we cannot attend, but have enclosed my/our contribution of $__________. For compliance with New York State Election Law and campaign guidelines, please complete the following. Name: _______________________________________________ Residential Phone: ______________________________________ Employer: ____________________________________________ Business Phone: _______________________________________ Title/Occupation: ______________________________________ Primary Fax: __________________________________________ Mailing Address: ______________________________________________________________________________________________ City, State, Zip: ________________________________________ E-mail: ______________________________________________

For Contributors Only. Each contribution must be accompanied by a completed and signed contribution form. Contributions by check Please make checks payable to PATERSON FOR GOVERNOR and mail with this form to: 461 Park Avenue South, Floor 9 New York, NY 10016-6822

Contributions by credit card Credit card contributions may be faxed to 212-370-7750. Card Number: _________________________________________ Amount: $__________ Type: ________ Expiration Date: _______

The account being used to make this contribution is registered to and managed by a/an: ❍ Individual ❍ Partnership

❍ Sole Proprietorship ❍ Corporation

❍ PAC or Labor Union ❍ LLC

❍ Candidate Committee ❍ Party Committee

For non-individuals, please provide the contributing entity’s name: _______________________________________________________________ Contribution limits and guidelines for Paterson for Governor: Paterson for Governor will accept no more than $55,900 for the 2010 election cycle ($18,100 for the primary/$37,800 for the general) from individuals, LLCs, unions, political action committees, and trade associations. Partnerships that contribute in excess of $2,500 total over the course of the cycle will be required to specifically identify the partner(s) responsible for the contribution(s), and the attributed amount will be counted against each partner’s individual contribution limit. Total contributions from a corporation may not exceed $5,000 per calendar year aggregate to all New York state and local candidates and committees. It is strictly prohibited to reimburse another individual’s or entity’s contribution. All contributors must be either US citizens or permanent resident aliens (green card holders). No state agency officer or employee who serves at the pleasure of the governor or their appointing authority may contribute to and/or fundraise for the governor’s campaign. Appointed members of state public authorities or other boards, commissions, and departments must ascertain if they are barred by Executive Order 7 from contributing to and/or fundraising for the governor’s campaign. Contributions are not deductible for federal income tax purposes.

By signing below, you hereby affirm that your contribution does not violate the terms specified above.

Signature Required: _________________________________________________________ Date: ________________ If you have any questions, please contact Kristie Stiles, Managing Director, at 212-286-2010 or [email protected]. PAID FOR BY PATERSON FOR GOVERNOR

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