Individual Donation & Certification Form 2020

Please help us support our Democratic candidates and promote public programs and policies in line with our Democratic values.

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Email*

Send me updates by email(not needed for receipts)

Phone*

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* By providing your phone number, you are consenting to receive text message updates, including automated text messages, to that number from Madison Democratic Town Committee. 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

Postal Code*

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

Employer*

Principal Occupation: If self-employed provide Job Description. (Examples: Painter, Retired, Unemployed, Student, Homemaker)

Occupation*

Are you 18 years of age or older?*

Are you a communicator lobbyist?*

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

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

Are you an elected public official?*

Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services?*

Confirmation*I hereby certify and state that all of the information disclosed by me and set forth on this online contributor form 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 I have provided my residential address. I certify that this contribution is being made on my personal credit or debit card for which I have a legal obligation to pay from my own 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 the funds of a corporation, labor organization or any other entity.  NOTE: Total contributions from an individual to a Town Committee may not exceed $2000 in a calendar year.  For definitions of "communications lobbyist" and "state contractor" please go to: https://seec.ct.gov/Portal/data/forms/SampleForms/definition_of_terms_party_committee_01042016.pdf

Paid for by Madison Democratic Town Committee

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