OFFLINE DONATION FORM

EMPLOYER INFORMATION

Required for contributions over $51 under Maryland campaign finance law.
Which one applies to you?
Employer or Business Name
Occupation/Job Title
Employer or Business City & State
CONTRIBUTION INFORMATION
Contribution Amount
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Payment Method (Check one):
Check Number (if applicable):
CERTIFICATION
NOTICE

Maryland law requires political committees to report the name, address, employer and occupation of the individuals contributing more than $51. Contributions are subject to limits and reporting requirements under Maryland election law. For more information contact the Maryland State Board of Elections.
By signing below, I certify that:
- I am making this contribution with my own personal funds.
- I am not making this contribution on behalf of another person.
- I am not a coroporation, labor union or foreign national making this contribution.
- The information provided above is accurate to the best of my knowledge.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FOR CAMPAIGN USE ONLY
Date Recevied

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Received By
Date Deposited
Receipt/Contribution ID:
Should be Empty:

DONOR INFORMATION