Chandra for Ohio Donation Form by billycorgann


									                  Chandra for Ohio Donation Form

Full Name: ___________________________________________________________

Address Line 1_________________________________________________________

Address Line 2:________________________________________________________

City:___________________________________ State:__________ Zip:___________

Office phone: ___________________ Home phone: __________________________

Email (please provide): __________________________________________________

Employer: ____________________________________________________________

Occupation: __________________________________________________________

Checks preferred, or please use credit card if more convenient.

Credit Card Type (Please circle one):

Visa   MasterCard     Discover      American Express

Expiration Date: ______________________________

Card Number: _________________________________________________

Amount: $_______________________ (individual limit is $10,000)

All contributors must confirm that the following statements are true. Your
contribution cannot be accepted unless each box is checked.

    This contribution is made knowingly and voluntarily from my own funds, not
     those of another, and the contribution is not controlled by another individual
     or made from the proceeds of a gift given to provide funds to be contributed.
    This contribution is not made from the general treasury funds of a
     corporation, labor organization, or national bank.
    I am not a foreign national who lacks permanent resident status in the U.S.
    I do not personally contract with the federal government for personal services
     or the sale of goods, land, or buildings.

                                          1                       Created on 6/1/2005 12:11 PM
    I affirm that this contribution is made either by personal check or on a
     personal credit card for which I have the legal obligation to pay, and not
     through a corporate or business-entity card or the card of another.
    I am not personally a provider of services or goods who receives payment
     from the Ohio Department of Job and Family Services’s Medicaid program.

* Contributions to Chandra for Ohio are not deductible as charitable contributions
  for Ohio income-tax purposes. Ohio law, however, permits a dollar-for-dollar tax
  credit for contributions made to a statewide candidate, up to an annual limit of
  $50 for single filers and $100 for joint filers. Chandra for Ohio does not intend to
  solicit Attorney General employees.


Please mail to Chandra for Ohio or fax to 216.561.5974.

Chandra for Ohio
Attn: Robert Anderle, Treasurer
c/o Dingus & Daga, CPAs
20600 Chagrin Boulevard—Tower East, Suite 701
Shaker Heights, Ohio 44122.5398

If you have questions concerning your donation, please e-mail Treasurer Rob Anderle
at or call him at 216.443.2554.

I would like to volunteer. Here are some other ways I think I can be helpful:


Paid for by Chandra for Ohio, Robert Anderle, Treasurer.

                                           2                     Created on 6/1/2005 12:11 PM

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