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Before we can accept your online payment we must receive your completed Individual Contributor Certification Form. Once you have completed the form, you will be redirected to our online payment site where you can make a credit card contribution.
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Individual Contributor Certification Form
Cummings for the 74th

NAME OF INDIVIDUAL CONTRIBUTOR

EMAIL OF INDIVIDUAL CONTRIBUTOR

CONTRIBUTION AMOUNT
PHONE NUMBER RESIDENTIAL ADDRESS CITY STATE ZIP CODE
EMPLOYER PRINCIPAL OCCUPATION
If self-employed, provide Name of Business Example: Dave’s Painting Other Examples: Retired, Unemployed, Student, Homemaker If self-employed, provide Job Description Example: Painter Other Examples: Retired, Unemployed, Student, Homemaker
Age?
 18 or older 12 to 17 under 12

Please answer each of the following:

Are you a communicator lobbyist OR the spouse or dependent child of a communicator
lobbyist?
Communicator lobbyists may not make contributions to statewide or General Assembly
candidates during the legislative session.
 Yes No
Are you a principal of a state contractor or prospective state contractor?
 Yes No
If yes, please indicate which branch or branches of government the contract(s)
is with:
 Legislative Executive

CERTIFICATION

 I certify that I am NOT a principal of a state contractor or prospective state contractor.
(see Definition of Terms)

 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 I have provided my residential address.

 I certify that this contribution is made on my personal debit or credit card for which I have a legal obligation to pay and intend to pay from my own personal funds, is not being reimbursed in any manner, is not being made as a loan, is not an otherwise prohibited contribution, and that payment on this card is not made from the funds of a corporation, labor organization or any other entity.

 I hereby certify that all of the information disclosed by me on this contributor form is true and accurate to the best of my knowledge and belief.