Layne for 144

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 Layne for 144. 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.

Are you currently employed?*

YesNo

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) **

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

YesNo

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

Are you a state contractor or a prospective state contractor?*

If yes, please indicate which branch or branches 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.

Age*

Requirement*

I certify that I am NOT under the age of 18.

I certify that I am NOT a principal of a state contractor or prospective state contractor.

I certify that I am a United States citizen or a foreign national 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 contribution form is true and accurate to the best of my knowledge and belief.

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