CHECK MADE PAYABLE TO: Hillsborough County Medical Association
2012 CREDIT CARD PAYMENT: Master Card Visa AmEX
DUES STATEMENT PLEASE COMPLETE & SIGN
Card # ___________________________________ Exp. Date _____________
Hillsborough County Medical Assn.
606 S. Boulevard Three or four digit pin # on back of credit card _____________
Tampa, FL 33606 Authorized Signature _______________________________________________
Billing address of credit card:_________________________________________
Daytime phone: ( _______) __________ - _____________
Payment total: $______________________
Phoned in by: _______________________
PAYMENT IS FOR: HCMA HILLPAC FOUNDATION
*See below for a convenient way to pay your dues*
Association dues are due and payable January 1. Dues are delinquent after February 1 and members are dropped for non-payment after April 30.
HILLSBOROUGH COUNTY MEDICAL ASSOCIATION
Annual Dues $____________
Membership Category: __________________
HILLPAC- Hillsborough Political Action Committee 50.00
HCMA Foundation* 100.00
TO ENSURE PROPER POSTING, PLEASE ENCLOSE A COPY TOTAL
OF THIS STATEMENT WITH YOUR PAYMENT REMITTED: $ ____________
*Your contribution may be tax deductible.
HCMA Members are offered the option of automatic renewal. By signing below you will authorize the
Hillsborough County Medical Association to automatically charge the above credit card to renew your
dues in August of each year. To participate in this program, please sign below:
X___________________________________________ Printed name: ________________________________________
Your Continued Support is Greatly Acknowledged!
FOR YOUR RECORDS, PLEASE NOTE THAT THE REVENUE RECONCILIATION ACT OF 1993 STATES THAT ASSOCIATION DUES USED FOR
LOBBYING ACTIVITIES ARE NOT DEDUCTIBLE AS A BUSINESS EXPENSE. 1.5% OF YOUR HCMA DUES FOR 2012 CANNOT BE DEDUCTED AS A
BUSINESS EXPENSE FOR FEDERAL INCOME TAX PURPOSES. The estimated portion of your 2012 dues dedicated to lobbying activities for
HCMA is 1.5%.
ASSOCIATION DUES ARE NOT DEDUCTIBLE AS A CHARITABLE CONTRIBUTION FOR FEDERAL INCOME TAX PURPOSES, BUT MAY BE PARTIALLY
DEDUCTIBLE AS A BUSINESS EXPENSE. PLEASE CONSULT YOUR TAX ADVISOR.