Ohio's Future PAC - Contribution Form

Print this form and mail with check or credit card information to:

P.O. Box 7

Terrace Park, OH 45174

NAME: ____________________________________________________

ADDRESS 1: _______________________________________________

ADDRESS 2: _______________________________________________

CITY: ________________________ STATE: _____ ZIP: ___________

PHONE: ___________________________________________________

EMAIL: ___________________________________________________

EMPLOYER: _______________________________________________

OCCUPATION: _____________________________________________

U.S. Citizen: ( y / n )

PAYMENT INFO

AMOUNT: $25 / $50 / $100 / $500 / Other _______

PAY BY: CHECK / CREDIT CARD (Please circle one)

CHECKS PAYABLE TO: Ohio's Future PAC

CARD TYPE : VISA / MASTERCARD (Please circle one)

CARD #: __________________________________________________

CARD VERIFICATION #: ________ EXP DATE: ________

NAME ON CARD: _________________________________________

SIGNATURE: _____________________________________________

Contribution to Ohio's Future PAC are not deductible as charitable donations for federal income tax purposes. Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation, and name of employer individuals who contributions exceed $200.00 in a calendar year. Corporate contributions, and contributions from labor unions, government contractors and foreign nationals are prohibited. Contributions to Ohio's Future PAC are subject to the limits and restrictions of federal law.

Paid for by Ohio's Future PAC, Nancy Aichholz, Secretary, 8405 Indian Hill Rd. - Cincinnati, OH 45243. Not authorized by any candidate or candidate committee.