I am a business or other entity, and this contribution is from my expense funds. [Enter business name above]
This is not my residence address.
This is my residence address (required for public matching funds).
Yes, I am an individual, and this contribution is from my personal funds.
Campaign finance law requires us to obtain your occupation and employer.
Please complete even if self-employed; enter 'none' or 'retired' if unemployed.
If self-employed, enter the name of your business; if unemployed enter 'none' or 'retired'.
e.g. 1234 Main St., My Town, NY 01234. (If unemployed, enter 'none')