Individual Contributor Certification Form - Ledyard Democratic Town Committee

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Fill out the google form below or click below to download and mail in the contributor form.

Contributor Form - page 1 (Download at https://www.ledyarddtc.com/uploads/6/3/3/4/63340137/p-form.pdf)

Contributor Form - page 2 (Download at https://www.ledyarddtc.com/uploads/6/3/3/4/63340137/p-form.pdf)

Name of Individual Contributor *

Contribution Amount *

Is the contribution being made from the account of a sole proprietorship? *

Yes

If yes, and name is different than individual contributor, list NAME OF SOLE PROPRIETORSHIP

Residential City *

Residential Street Address *

Residential State *

Residential Zip Code *

Are you 18 or older? *

Yes

If you are not 18 or older please list your age:

Employer *

Prinicipal Occupation *

Are you a lobbyist? *

Yes

Are you the spouse or dependent child of a lobbyist? *

Yes

If this is a contribution to a candidate committee or exploratory committee for Chief Executive Officers of a municipality (mayor, first selectman) answer the following: Do you or a business with which you are associate have a contract with the town, city, or borough in which the candidate is running that is valued at more than five thousand dollars?

Yes

Clear selection

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. *

Your typed name below represents your signature

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