JAC Candidate Donation Form
Donation to Titus
(Please print and fill out this form completely and mail with contributions to
JAC, PO Box 105, Highland Park, IL 60035)
Contributor’s Name ______________________________________________________
Address _______________________________________________________________
City ________________________________________ State ______ Zip ___________
Phone _________________________ Business Phone ________________________
E-mail ___________________________________ FAX ________________________
Occupation ____________________________________________________________
Employer ______________________________________________________________
Personal Check (payable to Dina Titus for Congress)
Amount $_________________________
Visa MasterCard
Card number ______________________________________ Expiration date ________
Signature _______________________________________________________________
Federal law requires political committees to report the name, mailing address, occupation and employer for each individual whose contributions aggregate in excess of $200 in a calendar year. According to law, JAC cannot accept corporate contributions. Membership, gifts, or other payments to JAC are not deductible as charitable contributions for federal income tax purposes.