Jadon for the 50th

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

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Residential Address*

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Are you currently employed?

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If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide the Name of Business. (Example: Dave's Painting.) If self-employed, Provide Job Description. (Example: Painter)

Is contribution being made from the account of a sole proprietorship?*

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If yes, and the name is different than the individual contributor, list NAME OF SOLE PROPRIETORSHIP

Age Please see restrictions regarding contributions from minors*

Are you a principal of a state contractor or prospective state contractor? If Yes, please indicate which branch or branchess of government the contract(s) is with*

Are you a communicator lobbyist, OR the spouse or dependent child of a communicator lobbyist? (Communicator lobbyists may not make contributions to general assembly candidates during the legislative session.)*

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Requirement (copy)*I certify that I am NOT a principal of a state contractor orprospective state contractor. I certify that I am either a United States citizen or a foreignnational with permanent resident status in the United States. I certify that I have provided my residential address. I certify that this contribution is being made on my personal debit or credit card for which I have legal obligation to pay and intend to pay from my own personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution and that payment is not made from the funds of a corporation, labor organization, or any other entity. I hereby certify that all information disclosed by me on this contributor form is true and accurate to the best of myknowledge and belief. <a href="https://seec.ct.gov/Portal/data/forms/SampleForms/definition_of_terms_general_assembly_01042016.pdf" rel="noopener noreferrer" target="_blank" style="color: rgb(0, 102, 204);">Click here to read legal definitions</a>.

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