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*Required for single contributions exceeding $50 or multiple contributions from a single source exceeding $50 in the aggregate per election.

CONTRIBUTION:

Date Given ............... Amount (max. $1000) $

DECLARATIONS:

The contribution listed above was freely and voluntarily given by me from my personal property.

I have not, directly or indirectly, been compensated or reimbursed for the contribution listed above.

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Please Note: Contributions are not tax deductible. Contributions from Corporations, Foreign Nationals, and Federal Contractors are not permitted.

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