INDEPENDENT PARTY NORWALK TOWN COMMITTEE

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Please check if you are under 18

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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.

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I hereby certify and state that all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief.

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