Please complete and mail to:

Friends of Stephen Harrison

544 Bay Ridge Parkway

Brooklyn, NY 11209

When donating funds by check, please print and fill out and sign this page. Federal law requires political committees to use their best efforts to collect and report the name, address, occupation and employer of each individual that contributes more than $200 in a calendar year. Contributions are limited to $2,300 per individual per election. Contributions are not tax-deductible. Contributions from corporations, people under the age of 18 and foreign nationals are prohibited.

Your Name:

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City, State, ZIP:

Occupation:

Employer:

By donating to Friends of Stephen Harrison, you certify that the following statements are true:

1. I am a United States citizen or a permanent resident alien.

2. This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution.

3. I am not a federal contractor.

4. I am at least eighteen years old.

Signature

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