Litchfield RTC

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If multiple employers and one is state contractor, list the state contractor. If self-employed, provide name of business. (Example: Dave's Painting. Other Examples: Retired, Unemployment, Student, Homemaker)

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

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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.

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 made on my personal debit or credit card for which I have legal obligation to pay and intend to pay from my personal funds, is not being reimbursed in any manner, is not being made as a loan, is not an otherwise prohibited contribution, and that payment on this card is not made from funds of a corporation, labor organization or any other entity.

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LITCHFIELD REPUBLICAN TOWN COMMITTEE

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