I hereby certify that all of the information disclosed by me and set forth above on this form is true and accurate to the best of my knowledge and belief. 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 this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution. I herby agree to the following terms as well: http://fairfieldrtc.com/donation-form-details/