Connecticut Citizens For Ballot Initiative

Contributions For the Ballot Initiative

To contribute, please print this page, complete and mail contribution to:

Connecticut Citizens For Ballot Initiative
P.O. Box 684
South Windsor, CT 06074-3747

Name: _____________________________________________________________________

Residential Address: ___________________________________________________________

City, State Zip: _______________________________________________________________

Best Phone Number: ________________________________
                                 Cell:  ________________________________
                             Work:  ________________________________
                            Home:  ________________________________

Best Email:  _________________________________________________________________
          Alternate Email:  __________________________________________________________

Over Age 18? (Y/N):  ___________                                              Marital Status:  _____________________
Employer:  _______________________________          Occupation/Position:  _________________

Contribution Amount: $_____________  ($750 maximum per person, $30 maximum if under 18 years old)

___ Cash   ___ Check   ___ Money Order   ___ Debit Card   ___ Credit Card
Card Type:  ___________________    Name on Card:  __________________________________
Acct #:  __________________________________  Exp Date:  ___________  Sec. Code:  _______

I understand that if I am under 18 years of age, the maximum annual contribution I am allowed to give is $30

I affirm that I am either a United States citizen or a foreign national with permanent resident status in the United States.

___ Yes  ___ No   Are you a lobbyist, lobbyist spouse, or lobbyist dependent?

___ Yes  ___ No   Do you, or a business with which you are associated, have a contract with the state valued at more than $5,000?

I understand that I have a legal obligation to pay and intend to pay from my own personal funds; payment is not made from the funds of a corporation, labor organization or any other entity.  I understand that donations to the Connecticut Citizens For Ballot Initiative are not tax-deductible because Connecticut Citizens For Ballot Initiative is a State Political Action Committee (PAC).

Signature:  _____________________________________________  Date:  ________________

Any questions about contributing, contact our treasurer at (860) 644-2431

100% of our contributions go to making positive change in our state.

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