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Bill Haney for U.S. Congressman Contribution Form

Date: ________________________________________________________________________________________________

Name: _______________________________________________________________________________________________

Address: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Phone: _______________________________________________________________________________________________

e-mail: _______________________________________________________________________________________________

Occupation and Employer: _______________________________________________________________________________

Signature(s): __________________________________________________________________________________________

I would like to participate at the following level with a check/money order in the amount of: ______________

Contributions should be made payable and mailed to:

Bill Haney for Congressman

P.O. Box 776

Brunswick, OH 44212

www.billhaney.org

contact bill@billhaney.org or call 330-220-7134 for questions

Contributions of gifts to Bill Haney for Congressman are not tax deductible. Individual contributions can not exceed $2,400 per election or a total amount of $4,800 per election cycle. Federal law prohibits contributions to the campaign for corporations. If this contribution is from more than one individual, such as from a wife and husband, please provide the requested information and signature for each. If two signatures are provided, you both affirm that your contribution is made from a joint account. To comply with federal law, we must use best efforts to obtain, maintain and submit the name, mailing address, occupation and name of employer for individuals whose contributions exceed $200 per election cycle.

Paid for by Haney for Congressman; Tom Biller Treasurer