The New Jersey Democratic State Committee

Neighborhood Leader

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First Name
Last Name
Address
City
State
Zip Code
Home Phone
E-Mail Address
Contribution Amount	(example: $100)
Name as it appears on the card
Credit Card Type	Visa MasterCard Discover
Credit Card Number
Credit Card Security Code	Click here for Explanation
Expiration Date
Employer
Occupation

Federal law requires political committees to report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 in a calendar year. Check here if self-employed I confirm that the following statements are true and accurate: I am at least 18 years old. I am a United States citizen or a permanent resident alien. This contribution is not made from the general treasury funds of a corporation, labor organization or national bank. This contribution is not made from the treasury of an entity or person who is a federal contractor. The funds I am donating are not being provided to me by another person or entity for the purpose of making this contribution. Paid for by Dollars For Democrats®, 430 South Capitol Street, SE, Washington, DC 20003, and is not authorized by any candidate or candidate's committee. Your contribution may be used in connection with Federal elections and is subject to the prohibitions and limitations of the Federal Election Campaign Act. For the purposes of Federal contribution limits, the entire amount of your donation will be considered a contribution to the State Democratic Party. Donations are not U.S. tax deductible.