Citizens to Elect Jacqueline Y

Citizens for Jacqueline Collins

P.O. Box 209054 Chicago, IL 60620

Ph: 312-846-1254/ Fax: 775-417-1997

Please help us comply with Campaign disclosure law that requires political committees to use their best efforts to collect and report
the name, occupation and employer for each individual whose aggregate contributions are in excess of $150 in a reporting cycle.

Name: (Please print) _______________________________________________________________________

Home Address:

_______________________________________________________________________________________

Number and Street City State Zip

Business Address:

_________________________________________________________________________________________

Number and Street City State Zip

Telephone: Wk:________________________ Hm:______________________ Cell:_______________________

Email: _____________________________________________________________________________________

__________________________________________________________________________________________

* Employer Name * Occupation

Amount of Contribution: $___________________

Check_________ Please make checks payable to: Citizens for Jacqueline Collins

Credit Card: Visa_____ MasterCard______ American Express______

Account#_______________________________________ Security Code _____________

Exp. date___________________ FundRaiser/Event: ______________________________

Note: When contributing by personal credit card, please ensure the address to which the credit card is issued, matches one

of your addresses given above.

Please mail to: Citizens for Jacqueline Collins, P.O. Box 209054 , Chicago , IL 60620

or fax to: 775-417-1997.

Signature: __________________________________________________________ Date: ________________

I would like to:
__Hold a fundraiser or coffee. __Make phone calls for Jacqui.
__Put up yard signs.
__Work the door at events.

__Volunteer in the office.
__Canvass door-to-door.
__Stuff envelopes.

__Volunteer in the field.
__Distribute pamphlets.
__Do research.

Thank you for your support!

Paid for and authorized by Citizens for Jacqueline Collins. Candidates are required to report the name, mailing address, employer and occupation for individuals with aggregate contributions over $150 in a reporting cycle. A copy of our report filed with the State Board of Elections and the County Clerk is available for purchase from the State Board of Elections, Springfield Illinois and from the Cook County Clerk’s Office, Cook County Administration Building 69 W. Washington St., Suite 500, Chicago, Illinois. Contributions to candidates running for state office are not deductible as charitable contributions for federal income tax purposes.