Friends of Maurice Hinchey

* Required Fields

Personal Information

First Name *

Last Name *

Middle

Address *

City *

State *

Zip *

Email *

Home Phone *

Work Phone

Ext.

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Employment Information

Employer *

Occupation *

To comply with Federal law, contributors are required to provide their employment information. If you are retired, please enter N/A under Employer and Retired under Occupation ; if a homemaker, please enter N/A - Homemaker; if self-employed, please enter "Self-Employed" under Employer and describe your line of work under Occupation.

Contribution Information

Amount *
$

I would like this contribution to automatically recur:

Until I contact you
Until the following date: Month Year

Payment Information

Card Number *
Visa

Card Expiration *

Confirm Eligibility

* I confirm that the following statements are true and accurate:

- I am not a foreign national who lacks permanent residence in the United States.
- I am not a Federal government contractor.
- This contribution is made from my own funds, and not those of another.
- This contribution is not made from the funds of a corporation or labor organization.
- This contribution is made on a personal credit card or debit card for which I have the legal obligation to pay, and is not made either on a corporate or business entity card or on the card of another person.
- I am at least eighteen years old.

Federal law requires us to use our best efforts to collect and report the name, address, occupation and name of employer of individuals whose contributions exceed $200 per election cycle.

We may accept contributions from an individual totaling up to $2,300.00 per election.

Contributions or gifts to Friends of Maurice Hinchey are not tax deductible.