Richard Reichard  for Congress Contribution Form

Yes, I want to support Richard Reichard for Congress!


Please make checks payable to "Richard Reichard for Congress"

and mail it to the address below:

41 Challenger Drive,

Staten Island, NY 10312


My Contribution is: __$25 __ $50 __ $75 __ $100 __ $250 __ $500 Other $_____

To comply with federal campaign finance rules, please provide the following information:


Name _______________________________________________________

Home Address _________________________________________________

Employer ______________________ Occupation ______________________

Work Address (optional) __________________________________________

Home Phone (optional)_____________ Work Phone (optional)______________

Email (optional)__________________ Fax Number (optional)______________


I hereby affirm that this contribution is being made from my personal funds, is not being reimbursed

in any manner, and is not being made as a loan. I am a United States Citizen or permanent resident

alien; I am not a contractor with the United States government; and I am not a business entity taxed

as a corporation.  An individual may contribute a maximum of $2,700 per cycle

(primary/general total $5,400) to the campaign.  PACs can contribute up to $5,000

(primary/general total $10,000) to the campaign.  Contributions or gifts to

Richard Reichard for Congress are not tax deductible for federal income tax purposes.  Federal law

prohibits the acceptance of contributions from corporations and other entities taxed as corporations.


______________________________ _______________

Contributor’s Signature                                     Date


Paid for by Richard Reichard for Congress, Nick Popolo, Treasurer