DS9 Document EFTA01093078

C O N G R E S S Please join Bill & Lori Bernstein, Michael Fricklas, and Claire Silberman For a reception with Congresswoman Diana DeGette Member, Energy and Commerce Committee Chief Deputy Whip Co-Author of Bipartisan 21" Century Cures on Monday, May 9th, 2016 6:30 P.M. - 8:30 P.M. at The Home of Bill Bernstein 455 Central Park West New York, NY loo25 Contribution Levels Chair - $2,700 • Host - $1,000 Supporter - $500 • Friend - $250 To RSVP, please contact Riley Voss at or Authorized by Diana DeGette for Congress, Inc. EFTA01093078 DEG CITE C O N G R E S S Thank you for your Support! I would like to attend the event as a Chair and contribute $2,700. I would like to be listed as an event Chair: Yes No I would like to attend the event as a Host and contribute $1,000. I would like to be listed as an event Co-Host _Yes No I would like to attend the event as a Supporter and contribute $500. I would like to attend the event as a Friend and contribute 5250. I am unable to attend but would like to contribute $ Name: Address: City, State Zip: Phone number. Email: Occupation: Employer: Please make checks payable to: Diana DeGette for Congress PO Box 61337 Denver, CO 80206 Contributions can be made online: www.degette.com Please bill my personal credit card: D Visa O MasterCard O AMEX O Discover Amount: $ Expiration: Card Number. Security Code: (for American Express only): Name as it appears on the card: Signature: Maximum contribution $5,400 per person — $2,700 Primary Election, $2,700 General Election By signing above, you authorize us to charge your card in the amount indicated. You also affirm that your contribution is made from personal funds and not from funds otherwise prohibited by law. Under federal law, an individual may give up to $2,700 per election (primary and general) for a total of $5,400 to a federal candidate and no more than $48,600 during a two-year cycle to all federal candidates. Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and employer of individuals whose contributions exceed $200 in an election cycle. Authorized by Diana DeGette for Congress, Inc. EFTA01093079