Congressman Tim Walberg
Senate Majority Leader Randy Richardville
State Representative Dale Zorn
Monroe County Commissioner & Monroe County GOP Chairman Jason Sheppard
Monroe County Commissioner Henry Lievens
for a reception honoring
THE HONORABLE PETE HOEKSTRA
Candidate for United States Senate
Tuesday, October 18, 2011
The Home of Jason and Melissa Sheppard 7235 Bent Creek | Temperance, MI 48182
Host Committee and Sponsor Reception
Host Committee: $500 per person Sponsor: $100 per person
6.45pm-8.00pm General Reception
Guest: $50 per person
Kindly reply to Lauren Gervason at 248.670.4015 or *protected email*
￼Paid for by Hoekstra for Senate
10.18.11 Temperance Fundraiser REPLY FORM
First Name: ______________________________________ Last Name: __________________________________________________ Address: _____________________________________________City: __________________________ State: _____ Zip Code: ______ Phone: ________________________ Email: _____________________________________________________________________
** This contribution is made by check or credit card from my personal funds and is not drawn on an account maintained by an incorporated entity. I am a U.S. Citizen or permanent resident and this contribution will not be reimbursed by another person.
** By law, the maximum amount an individual may contribute is $5,000 ($2,500 for the primary election and $2,500 for the general
election). Couples may contribute a maximum of $10,000 ($2,500 per person, per election). For a contribution from a joint account to be attributed to two individuals, both must sign this form, indicating agreement with the above statement.
Joint Contributor Name: _____________________________ Joint Contributor Signature:_________________________________
Federal law requires us to use best efforts to obtain and report the name, mailing address, occupation and name of employer for individuals whose contributions aggregate in excess of $200 per election cycle. If you are not employed or retired, please enter N/A.
Occupation ______________________________________ Employer _______________________________________ Joint Contributor Occupation __________________________ Joint Contributor Employer _______________________
___ I/We will join the Host Committee at $500 per person
___ I/We will be a Sponsor at $100 per person
___ I will attend the Reception at $50 per person
___ No, unfortunately, I/we cannot attend. However, enclosed is my/our special contribution of $____.
The maximum amount individuals may contribute is $5,000 ($2,500 per election, both primary and general). Federal multi-candidate
PACs may contribute $10,000 ($5,000 per election). Contributions are not tax deductible as charitable contributions for federal income tax purposes. Contributions by corporations, foreign nationals (non-green card holders), labor unions, and federal government contractors are prohibited.
Payment Information: ____ Please find my contribution enclosed. _____ Please charge my contribution to my credit card. Please make checks payable to “Hoekstra for Senate,” and mail to C/O Lauren Gervason, PO Box 1862, Birmingham, MI 48012.
For credit card replies, please email form to *protected email* or fax to 248.670.4015.
AmEx: _____ MasterCard: _____ Visa: _____ Discover: _____
Credit Card Number: _________________________________________________________ CVV Number: _____________________ Name on card: _______________________________________________________________________________________________ Expiration Date: ____________ Signature: ___________________________________________ Amount: _____________________
190 Monroe Ave NW, Ste 301 | Grand Rapids, MI 49503 | www.hoekstraforsenate.com | *protected email*