A Gala Evening in Support of Attorney General Eric Schneiderman

A Gala Evening in Support of Attorney General Eric Schneiderman Wednesday, km 20, 2012 • Cocktail Reception from 6:00,pin to 8:00pm • 1/11) Reception at 5:30pm Grand le New York • At Grand Central Terminal • New York Cip Join the Event Committee s YES, 1/we would like tojoin the Event Committee at the following levek O Chair: Pledge to contribute/raise $25,000 (4 passes to VIP Reception • 10 passes to general reception) O Vice Chair: Pledge to contribute/raise $10,000 (2 passes to VIP Reception • 10 passes to general reception) O Patron: Pledge to contribute/raise $5,000 (1 pass to VIP Reception • 10 passes to general reception) O Sponsor. Pledge to contribute/raise $2,500 (8 passes to general reception) O Friend: Pledge to contribute/raise $1,000 (3 passes to general reception) Make a Contribution YES, II we would like to mood the allortty general's campaign. O I/we will attend the reception and have enclosed my/our contribution of: O $25,000 0 $10,000 0 $5,000 0 $2,500 0 $1,000 O $500 0 Other: $ (minimum $500 per person) O I/we cannot attend, but have enclosed my/our contribution(s) of $ Name@ ofattendee(s): Nattte(s) of Emit Committee AlemberN who ittritedyou, if any: For compliance with New York State Election Law and campaign guidelines, please complete the following. Name: Residential Phone: Employer: Business Phone: Title/Occupation: Primary Fax: Mailing Address: City, State, Zip: E-mail: For Contributors Only. Each contribution must be accompanied by a completed and signed contribution form. -1 Contributions by check Please make cheeks payable to SCHNEIDERMAN 2014 and mail with this form to: I ISA Fulton Street, Suite 250 New York, NY'10038-2712 Contributions by credit card Credit card rontribations may be faxed to (866) 532-0379. Card Number: Amount: $ Type: Expiration Date: The account being used to make this contribution is registered to and managed by a/an: O Individual ) sole Proprietorship : ) PM: or 1.abor I ',lion O Candidate Committee O Partnership ) ( :orporatit in : )1.1.C: O Party Committee Contributing entity's name: Required Disclosure Statement for Schneiderman 2014: To the best of my knowledge neither I personally nor any entity which I own or control has any matter presently pending with the NYS Attorney General's office or has had any matter resolved within the last 90 days. This does not extend to attorneys or lobbyist representing persons or entities with matters before the NYS Attorney General's office. I am not a foreign national who lacks permanent residence in the United States. This contribution is from my own funds or from funds of the contributing entity indicated above. Signature Required: Date: In accordance with New York State law, Schneiderman 2014 will accept no more than $60,800 for the 2014 election cycle ($19,700 for the primary/$4(,100 for the general) from individuals, unions, political action committees, and trade associations, partnerships, limited liability partnerships (LLPs), and limited liability companies (LLCs). Partnerships (including LLPs) that make contributions in excess of $2,500 will be required to specifically identify the parmers responsible for the contribution. Total contributions from a corporation may not exceed $5,000 per calendar year, and total contributions from an individual may not exceed $150,000 per calendar year, aggregate to all New York state and local candidates and committees. It is strictly prohibited to reimburse another individual's or entity's contribution. All contributors must be either US citizens, US entities, or permanent resident aliens (green card holders). Contributions arc not deductible for income tax purposes. If you have any questions, please contact Michael Giaccio at sot: PAID FOR BY SCHNEIDERMAN 2014 Are :2012.06.20Galal EFTA01120391