Mike and Sarah for Darien Board of Selectman
Individual Contributor Certification Form
We are so grateful for your financial contribution to our campaign. Your contribution goes to help with the many activities needed to run a successful political campaign.

1) Fill out the below form with your name, address and a few required questions from the State Election Enforcement Commission.

Once you click "Submit" you will be prompted to click a redirect link to:

2) Contribute directly with your PayPal account or your Credit/Debit Card.

If you have any questions at all about this form or the contribution process, please e-mail mike.sarah4bos@gmail.com and we'll be happy to help you out. Thank you again for your contribution, and I hope I'll see you soon at one of our in-person campaign events.

Mike and Sarah

Qualifying Contribution Certification Form:

The information below is required by the State of Connecticut to be collected from each contributor every time a contribution is made. All items are required.

To review Legal Definitions, click https://seec.ct.gov/Portal/data/forms/SampleForms/definition_of_terms_party_committee_01042016.pdf
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First Name *
Last Name *
Email Address *
Phone Number *
Residential Street Address *
City, State, Zip Code *
Employer (Please note: if self-employed, provide Name of Business. Examples: Dave’s Painting, Retired, Unemployed, Student, Homemaker) *
Principal Occupation (Please note: if self-employed, provide Job Description. Examples: Painter, Retired, Unemployed, Student, Homemaker) *
Are you 18 years of age or older? *
Are you a communicator lobbyist? *
Are you the spouse or dependent child of a communicator lobbyist? *
If yes, are you an elected public official? *
Are you a principal of a state contractor or prospective state contractor? *
If yes, please indicate which branch or branches of government the contract(s) is with: *
If you answered “yes” to the previous question, are you an elected public official? *
Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services? *
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. *
Contribution amount *
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