ABCC NC PAC

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Residential Address*

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This form only accepts US addresses.

Requirement

I certify that the following statements are true and correct:

• This contribution is made from my own funds and not those of another.

• This contribution is not made from the general treasury funds of a corporation, business entity, labor unions professional association, or insurance company.

• This contribution is made on my personal credit card for which I have a legal obligation to pay and is not made on a corporate credit card.

Joint Contribution Information:

Please include the full name, employer and occupation of any joint contributor from a joint account.

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