| To contribute, please print this page, fill in your information, and mail to: Friends of Karen Boback P.O. Box 100 Harveys Lake, PA 18618 +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Contributor Information First Name: ________________________Last Name:__________________________________ Telephone: (________ ) _____________________________ E-mail Address: ______________________________________________ Mailing Address: Street: ______________________________________________ City, State: ___________________________________________________ Zip Code: ___________________ Contribution Amount: $ __________________ Payment Method: Personal Check Payable to Friends of Karen Boback (Do Not Send Cash) Occupation: _______________________________________________________________ Employer: _________________________________________________________________ +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Contributions to a political candidate are not deductible for income tax purposes. Contributions from corporations are prohibited. Federal Law requires that we report the name, mailing address, occupation and name of employer for each individual whose contributions exceed $250 in a calendar year. |