Heather Goetz for Simsbury

*Please review your contact and residential information to ensure it is accurate before submitting your contribution.

Choose Amount

Email*

Send me updates by email(not needed for receipts)

Phone*

Send me updates by text*

* By providing your phone number, you are consenting to receive text message updates, including automated text messages, to that number from Heather Goetz. Message & Data rates may apply, and message frequency may vary over time. Reply "STOP" to opt out of these text message updates.

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Employer*

If multiple employers and one is a state contractor, list the state contractor. If self employed, provide Name of Business. Example: Dave’s Painting; Other Examples: Retired, Unemployed, Student, Homemaker

Principal Occupation*

If self-employed, provide Job Description. Example: Painter; Other Examples: Retired, Unemployed, Student, Homemaker

Are you 18 years of age or older?*

$30 Maximum contribution if you are under 18 years of age.

Are you a lobbyist?*

Are you the spouse or dependent child of a lobbyist?*

Do you or a business with which you are associated have a contract with the town of Simsbury that is valued at more than $5,000?*

Card Number*

Exp. Date*

CVC / CVV*

Zip*