Contribution Form

Contribution Form You may also contribute online at hlMaryclinton.com/finance Total Amount $ Raiser Name/Code (If applicable) An individual may contribute up to $2,700 per election (the primary and general are separate elections). Couples may contribute up to $5,400 per election from a joint account. Federal multi-candidate PACs may contribute up to $5,000 per election. Contributions from corporations, labor organizations, foreign nationals, and federal government contractors arc prohibited. Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer of indi- viduals whose contributions exceed $200 in an election cycle. First St Last Name Address City/State/Zip Employer Occupation Email Cell Phone Home Phone Work Phone Second Name On Account, If Joint Account• 'Contributions will be evenly attributed between names. Second Name Employer Second Name Occupation By signing below. I certify that I am least 16 years old, I am a U.S. citizen or lawfully admitted permanent resident of the U.S., and the funds I am donating arc not being provided to me by another person or entity for the purpose of making this contribution. I also agree that the first $2,700 of my contribution will be designated for the 2016 primary election and any additional amount up to $2,700 will be designated for the 2016 general election. Signature Second Signature Please return completed form to the address below. ♦ Contribute by Personal Cheek Please make check payable to "Hillary For America" and mail, with completed form, to: ATTN: Finance Department • Hillary for America • P.O. Box1367. New York. NY 10185-1367 4 Contribute by Personal Credit Card 0 Visa 0 Mastercard 0 AMEX 0 Discover Card Number Exp Date Name As It Appears On Card Signature If you have any questions, please call-or email Contributions or gifts to Hillary for America are not tax deductible. Paid for by Hillary for America EFTA00301557