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Jaeger4Council

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Your contribution is greatly appreciated. Donations are limited to $250 per individual. Corporate and business contributions are prohibited by law.

To donate online, please click here.

To donate by mail, please make checks payable to "Jaeger4Council" and be sure to print the contributor card, fill it out completely and mail it with your check to:

Jaeger4Council

27 Maple Street, Apartment 2A

Norwalk, CT 06850

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Individual Contributor Certification Form

Jaeger4Council Committee

Name of Individual Contributor

Contribution Amount

Residential Address

Phone Number

City

State

Zip Code

Are you 18 or older?

Yes [ ] No [ ]

If you are not 18 or older, please list your age [ ]

Please answer each of the following:

Yes [ ] No [ ] Are you a lobbyist?

Yes [ ] No [ ] Are you the spouse or dependent child of a lobbyist?

CERTIFICATION

I hereby certify and state that all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief. I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States. I certify that this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

____________________________________ _______________________________

SIGNATURE OF CONTRIBUTOR DATE (mm/dd/yyyy)

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~Paid for by Jaeger4Council, Donna King, Treasurer~

Name of Individual Contributor	Contribution Amount

Residential Address	Phone Number

City	State	Zip Code	Are you 18 or older?
			Yes [ ] No [ ] If you are not 18 or older, please list your age [ ]

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