Nicole Roscoe for State Representative

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

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

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:*

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 branches of government the contract(s) is with*

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

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Requirement*

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

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 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 my knowledge and belief.

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