Please print, fill out and mail back with your contribution. Or click here to view and print in PDF format. Thank you.

_______  $10,000 max. amount per couple (primary & general)

      
_______  $5,000 max. amount per individual (primary & general)

  

_______

_______

_______

$2,500

$1,500

$1,000

  
      _______  $500
  _______  $100
  _______  Other amount please specify


PERSONAL CHECKS PAYABLE TO “WILDES FOR CONGRESS” PLEASE SIGN BELOW, ENCLOSE THIS LETTER, AND MAIL TO: WILDES FOR CONGRESS, P.O. BOX 5903, ENGLEWOOD, NJ 07631-5903

FEDERAL LAW REQUIRES OUR CAMPAIGN TO USE OUR BEST EFFORTS TO COLLECT & REPORT THE NAME, MAILING ADDRESS, OCCUPATION,AND EMPLOYER OF INDIVIDUALS WHOSE CONTRIBUTIONS EXCEED $200 PER ELECTION CYCLE.

PLEASE HELP BY SUPPLYING THE FOLLOWING:

Name: __________________________________________________________
Address: __________________________________________________________
Telephone: __________________________________________________________
Email: __________________________________________________________
Fax: __________________________________________________________
Occupation: __________________________________________________________
Employer: __________________________________________________________

PLEASE AFFIRM YOUR KNOWLEDGE AND COMPLIANCE WITH THE FOLLOWING BY SIGNING BELOW
1. Contributions to “Wildes for Congress” are not deductible for federal income tax purposes.
2. Contribution to “Wildes for Congress” is limited to $2,500 per individual per election period (primary/general). Contributions to the primary and general
election funds may be made at the same time, in one contribution. Therefore, an individual may contribute a maximum of $5,000 per election cycle.
3. If the contribution is drawn from a joint account, the campaign can accept a single contribution of up to $10,000 per cycle, attributed to both individuals,
either with both contributors’ signatures on the check or an accompanying letter. Please fill out above information for both individuals.
4. Contributions to “Wildes for Congress” are intended for use in connection with the U.S. Congress Election of 2014, and are subject to the prohibitions and
limitations of the Federal Election Campaign Act.
5. Contributions from corporations, national banks, federal contractors, labor organizations, professional organizations, and foreign nationals who are not permanent
residents of the United States are prohibited. I certify the donation does not come from the prohibited entities listed.
6. All contributions must be made from personal funds and may not be reimbursed or paid by any other person.
7. I permit “Wildes for Congress” to transfer my contribution in any manner in compliance with Federal and/or appropriate State Election laws.


Signature _____________________________________________

Date __________________________