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MALEK RESIDENCE
1259 CREST LANE, MCLEAN, VA 22101
Contributions are not tax deductible as charitable contributions for federal income tax purposes. By law, the maximum amount an individual may contribute is $2,500 ($5,000 per couple) per election. Federal multi-candidate PACs may contribute $5,000 per election. 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. Contributions by corporations, foreign nationals (non-green card holders), labor unions, federal government contractors, and minors under the age of 18 are prohibited.
Women for Romney Birthday Reception: Monday, April 16th REPLY INFO
q Yes, I will host the reception on April 16th. Enclosed is my contribution of $ __________ (Raise $10,000). q Yes, I will be attending the reception on April 16th. Enclosed is my contribution of $ __________ ($1,000 per person). q No, I am unable attend, but enclosed is a contribution of $________.
Please make your check payable to: Romney for President, Inc.
Name_________________________________________________________________________________________ Address_______________________________________________________________________________________ City____________________________________State______________________Zip__________________________ Home Phone____________________________________ Work Phone___________________________________ E-mail_________________________________________________________________________________________ CONTRIBUTOR INFO 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 or permanent resident and this contribution will not be reimbursed by another person. Signature_______________________________________________________________________ By law, the maximum amount an individual may contribute is $2,500 per person ($5,000 per couple) per election. For a contribution from a joint account to be attributed to two individuals, both must sign this form, indicating agreement with the above statement. Joint Contributor Signature_________________________________________________________ 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. Please complete the following: Occupation__________________________________________ Joint Contributor Occupation____________________________ CREDIT CARD REPLY Please charge my contribution of $___________ to my credit card. q Visa q MasterCard q AMEX q Discover Employer______________________________________ Joint Contributor Employer________________________
Account Number________________________________________
Expiration Date__________________________
Mail to: Romney for President, Inc. c/o Lisa Spies, 736 North Columbus Street, Alexandria, VA 22314 Or fax to: (202) 747-5777