US Congressman Elton Gallegly

Elton Gallegly for Congress

CONTRIBUTION FORM

□Yes! I support Elton Gallegly for Congress.

This contribution was referred by: First name _______________ Last name_______________________

 

[ ] Enclosed is my contribution by personal check (payable to Elton Gallegly for Congress) in the

amount of:

 

     [ ] $4,600 per couple (maximum primary donation) [ ] $2,300 per person (maximum primary donation)

     [ ] $1,000 per person [ ] $500 per person [ ] $250 per person [ ] Other $_____________

 

Please mail completed form with your donation (or address inquiries) to:

Elton Gallegly for Congress

PO Box 940001

Simi Valley CA 93094-0001

Phone: (805) 522-4487

 

ALL CONTRIBUTORS MUST COMPLETE THE FOLLOWING INFORMATION. WE ARE REQUIRED TO REPORT THE NAME, ADDRESS, OCCUPATION AND EMPLOYER OF ALL CONTRIBUTORS*.

 

______________________________________________  ___________________________________________________

Full Name                                                                                    Your Spouse’s Name & Signature (Required if Joint Contribution)

 

_____________________________________________ ___________________________________________________

Occupation                                                                                            Employer

 

__________________________________________________  _________________________________________________________

Spouse’s Occupation (Required if Joint Contribution)                    Spouse’s Employer (Required if Joint Contribution)

 

_________________________________________________________________________________________________________________

Your Address

 

__________________________________________________  ________________________                _________________________

City                                                                                                                        State                                                                  Zip Code

 

__________________________________________________            _________________________________________________________

Work Phone                                                                                                                 Fax

 

__________________________________________________             _________________________________________________________

Home Phone                                                                                                                 Cell Phone

 

______________________________________________________________________________________________________

E-Mail

 

 

Contributions are not deductible as charitable contributions for federal income tax purposes. *

 

Federal Election Law requires us to report the name, address, occupation, and employer for contributions aggregating in excess of $200 in an election cycle. The maximum an individual may contribute is $2,300 for the primary election and an additional $2,300 for the general election. Couples may contribute $4,600 for the primary and general elections, respectively. Federal PACs may contribute $5,000 for each election. Contributions from corporations, labor unions, federal government contractors, national banks, and foreign nationals without permanent residency status are prohibited.