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Certification: By submitting this form you state and certify that all the information disclosed and set forth above on this contributor card is true and accurate to the best of your knowledge and belief. You certify that you are either a United States citizen or a foreign national with a permanent resident status in the United States. This contribution is made on your personal credit card for which you have a legal obligation to pay and intend to pay from your own personal funds; payment on this card is not made from the funds of a corporation, labor organization or any other entity. You certify that this contribution is being made from your personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

* “Individual Contributor” means a human being, a sole proprietorship, or a professional service corporation organized under chapter 594a and owned by a single human being. A sole proprietorship is a business in which one human being owns all the assets, owes all the liabilities, and operates in his or her personal capacity. Any other type of business is not permitted to make a contribution, including LLCs. See General Statutes § 9-601 (9).

** You may enter an alternate address in lieu of your residential address only if you are admitted into the Address Confidentiality Program pursuant to General Statutes

§ 54-240 (a) or if you are one of the individuals with protected address status articulated in General Statutes § 1-217.

*** The law requires disclosure for each itemized contribution made by a lobbyist, the spouse of a lobbyist or any dependent child of a lobbyist who resides in the lobbyist’s household. General Statutes § 9-608 (c) (1) (H). The term lobbyist includes anyone required by law to register as a lobbyist with the Office of State Ethics because they (a) expend or agree to expend $3,000 or more in a calendar year on lobbying; OR (b) receive or agree to receive $3,000 or more in a calendar year for lobbying. General Statutes § 1-91 (as amended by Public Act 15-15). Individual lobbyists may contribute to candidate committees and exploratory committees for municipal office up to the limits for those offices.

**** A “business with which you are associated” refers to any business in which the contributor is a director, officer, owner, limited or general partner, or stockholder of 5% of more of the total stock of the business.

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